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Organization
SOUTH COUNTY MEDICAL
Active
Organization
SOUTH COUNTY MEDICAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICHARD LICON PA-C (CEO/PRESIDENT)
(949) 243-4741
Entity
Organization
Contact information
Practice address
36 BRASSIE LN, TRABUCO CANYON, CA 92679-4954
(949) 243-4741
(949) 713-5163
Mailing address
P.O. BOX 81044, RANCHO SANTA MARGARITA, CA 92688
(949) 243-4741
(949) 713-5163
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA11666
CA
Other
Enumeration date
12/08/2008
Last updated
11/14/2011
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