| Kenrick Licorish Medical Corporation | |
|
5201 Great America Pkwy Ste 320 Santa Clara CA 95054-1140 | |
| (408) 384-3758 | |
| Not Available |
| Full Name | Kenrick Licorish Medical Corporation |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 5201 Great America Pkwy Ste 320, Santa Clara, California |
| Authorized Official Name and Position | Kenrick Licorish (CORPORATION PRESIDENT / PHYSICIAN) |
| Authorized Official Contact | 9492440104 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Kenrick Licorish Medical Corporation 1968 S Coast Hwy # 2623 Laguna Beach CA 92651-3681 Ph: (408) 384-3758 | Kenrick Licorish Medical Corporation 5201 Great America Pkwy Ste 320 Santa Clara CA 95054-1140 Ph: (408) 384-3758 |
| NPI Number | 1518662485 |
|---|---|
| Provider Enumeration Date | 03/31/2023 |
| Last Update Date | 03/31/2023 |
| Certification Date | 03/31/2023 |
| Medicare PECOS PAC ID | 0446616023 |
|---|---|
| Medicare Enrollment ID | O20230524002226 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518662485 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| Provider Name | Kenrick B Licorish |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1144759085 PECOS PAC ID: 9133457765 Enrollment ID: I20190821000760 |
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