MEDICARE: TARA R MICICH

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	163W00000X	Registered Nurse	95419904	CA

General Provider Information

NPI Number	:	1174480719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA R MICICH

Provider Business Mailing Address
First Line	:	2410 S REDONDO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-2135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2410 S REDONDO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-2135
Country	:	US
Telephone Number	:	862-763-2079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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Directions to “ TARA R MICICH ” Practice Location

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