Healthcare Provider Details

I. General information

NPI: 1023053204
Provider Name (Legal Business Name): GLEN S LOVELACE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 1ST ST STE 260
BOISE ID
83702-6132
US

IV. Provider business mailing address

333 N 1ST ST STE 260
BOISE ID
83702-6132
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-3136
  • Fax: 208-345-0984
Mailing address:
  • Phone: 208-345-3136
  • Fax: 208-345-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM6570
License Number StateID

VIII. Authorized Official

Name: DR. GLEN S LOVELACE
Title or Position: OWNER
Credential: MD
Phone: 208-345-3136