MEDICARE: RICARDO LICONA RD

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1346060506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICARDO LICONA RD

Provider Business Mailing Address
First Line	:	3984 EPSILON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-4222
Country	:	US
Telephone Number	:	858-301-4946
Fax Number	:

Provider Business Practice Location Address
First Line	:	3984 EPSILON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-4222
Country	:	US
Telephone Number	:	858-301-4946
Fax Number	:

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

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	10/14/2024

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Directions to “ RICARDO LICONA RD” Practice Location

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