Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | A37875 | CA |
Y | 207RA0201X | Internist - Allergy & Immunology | A37875 | CA |
NPI | 1003947755 |
---|---|
Provider Name | Mr. Kenrick Anthony Licorish |
First Address | Santa Ana, CA 92702 |
Second Address | Santa Ana, CA 92701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2007 |
Last Update Date | 04/08/2008 |