Provider Demographics
NPI:1588827364
Name:PAELICKE, LORA A (RD)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:A
Last Name:PAELICKE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 SUNSET DRIVE, UNIT HALF
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6021
Mailing Address - Country:US
Mailing Address - Phone:323-236-9336
Mailing Address - Fax:
Practice Address - Street 1:4011 SUNSET DR
Practice Address - Street 2:UNIT HALF
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-1525
Practice Address - Country:US
Practice Address - Phone:323-783-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA961138133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA961138OtherCOMMISSION ON DIETETIC REGISTRATION