MEDICARE: JOSEPH ROBERT LOVELACE

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1194392480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH ROBERT LOVELACE

Provider Business Mailing Address
First Line	:	130 S 1300 E APT 507
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1736
Country	:	US
Telephone Number	:	208-861-4241
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 S 1300 E APT 507
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1736
Country	:	US
Telephone Number	:	208-861-4241
Fax Number	:

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

Provider Enumeration Date	:	06/07/2021
Last Update Date	:	06/07/2021

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