Provider Demographics
NPI:1467825703
Name:PAVICH, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:PAVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9411 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9345
Mailing Address - Country:US
Mailing Address - Phone:831-252-1114
Mailing Address - Fax:
Practice Address - Street 1:9411 SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9345
Practice Address - Country:US
Practice Address - Phone:831-252-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF001057822471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography