Provider Demographics
NPI:1528489283
Name:PAVLICEK, JUVAILA
Entity type:Individual
Prefix:
First Name:JUVAILA
Middle Name:
Last Name:PAVLICEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 N HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6121 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:MO
Practice Address - Zip Code:63134-2003
Practice Address - Country:US
Practice Address - Phone:314-615-0500
Practice Address - Fax:314-615-8303
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013020789133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013020781OtherLICENSE NUMBER