Organization
4TH STREET LASER & SURGERY CENTER INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ELAYNE CLARK RN CASC (ADMINISTRATOR)
(707) 546-8100
Entity
Organization
Contact information
Practice address
1720 4TH ST, SANTA ROSA, CA 95404-3602
(707) 546-8100
(707) 544-6438
Mailing address
1720 4TH ST, SANTA ROSA, CA 95404-3602
(707) 546-8100
(707) 544-6438
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
110000344
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110000344
STATE OF CA LICENSE
CA
05
—
SUR01428G
—
CA
Enumeration date
12/04/2006
Last updated
01/17/2013
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