MEDICARE: SOUTH COUNTY HEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	20A6613	CA

General Provider Information

NPI Number	:	1265802557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COUNTY HEALTHCARE

Provider Business Mailing Address
First Line	:	125 COLUMBIA
Second Line	:	A
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-4101
Country	:	US
Telephone Number	:	949-388-3131
Fax Number	:	949-429-0623

Provider Business Practice Location Address
First Line	:	125 COLUMBIA
Second Line	:	A
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-4101
Country	:	US
Telephone Number	:	949-388-3131
Fax Number	:	949-429-0623

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. PAUL ROBERT ADDISON
Credential	:	P.T.
Telephone Number	:	949-388-3131

Provider Enumeration Date	:	09/30/2015
Last Update Date	:	09/30/2015

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Directions to “SOUTH COUNTY HEALTHCARE ” Practice Location

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