Provider Demographics
NPI:1508473034
Name:ST FOUR SQUARE CLINICALS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ST FOUR SQUARE CLINICALS PROFESSIONAL CORPORATION
Other - Org Name:FOUR SQUARE CLINICALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:775-238-3082
Mailing Address - Street 1:650 N ROSE DR STE 472
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-7513
Mailing Address - Country:US
Mailing Address - Phone:714-345-6944
Mailing Address - Fax:844-872-5607
Practice Address - Street 1:100 N ARLINGTON AVE STE 340A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89501-1248
Practice Address - Country:US
Practice Address - Phone:775-238-3082
Practice Address - Fax:844-872-5607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility