4TH Street Laser & Surgery Center Inc

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

License

110000344 Issued in CA

Legal business name

4TH STREET LASER & SURGERY CENTER INC

Practice address

1720 4TH St
Santa Rosa, CA 95404-3602

Phone

(707) 546-8100

Fax

(707) 544-6438

NPI assigned

Dec 4, 2006

Last updated

Jan 17, 2013By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Elayne Clark, RN CASC

Title

Administrator

Phone

(707) 546-8100

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Listed as

4TH Street Laser and Surgery Center IncCCN 05C0001428

Medicare certification status

ActiveFrom the Provider of Services file

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Nina Ni, MD

  • Ophthalmology Physician
  • Santa Rosa, CA
  • NPI 1780959734
  NPD
• Daniel George Rich, M.D.

  • Ophthalmology Physician
  • Santa Rosa, CA
  • NPI 1710965058
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1358380800000",
    "number": "1902964174",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1720 4TH ST",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954043602",
            "telephone_number": "707-546-8100",
            "fax_number": "707-544-6438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1720 4TH ST",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954043602",
            "telephone_number": "707-546-8100",
            "fax_number": "707-544-6438"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "4TH STREET LASER & SURGERY CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-04",
        "last_updated": "2013-01-17",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "ELAYNE",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "707-546-8100",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "RN CASC"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "CA",
            "license": "110000344",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF CA LICENSE",
            "identifier": "110000344",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "SUR01428G",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• A Better Way Speech and Language Services, Inc
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• A-C Transportation Services Inc. (A-C Taxi)
• Charlene Abayon
• Marcus Abazia

• Ambulatory Surgical Clinic/Center in Santa Rosa, CA
• Providers in Santa Rosa, CA by specialty
• Ambulatory Surgical Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.