MEDICARE: LORA A PAELICKE 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	961138	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	961138	OTHER	CA	COMMISSION ON DIETETIC REGISTRATION

General Provider Information

NPI Number	:	1588827364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORA A PAELICKE RD

Provider Business Mailing Address
First Line	:	4011 SUNSET DRIVE, UNIT HALF
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-6021
Country	:	US
Telephone Number	:	323-236-9336
Fax Number	:

Provider Business Practice Location Address
First Line	:	4011 SUNSET DR
Second Line	:	UNIT HALF
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-1525
Country	:	US
Telephone Number	:	323-783-4011
Fax Number	:

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

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	10/27/2014

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