=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356710438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAUL JOHN LICATA MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2015
-----------------------------------------------------
Last Update Date | 09/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25431 CABOT RD STE 115
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-5518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-448-9728
-----------------------------------------------------
Fax | 949-448-9732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25431 CABOT RD STE 115
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-5518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-448-9728
-----------------------------------------------------
Fax | 949-448-9732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAUL JOHN LICATA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-448-9728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | A25662CA
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------