Provider Demographics
NPI:1447314174
Name:RANDY J LOVELL DO PC
Entity type:Organization
Organization Name:RANDY J LOVELL DO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-827-4307
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:THOMPSON FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59873-0969
Mailing Address - Country:US
Mailing Address - Phone:406-827-4307
Mailing Address - Fax:406-827-9514
Practice Address - Street 1:907 MAIN STREET
Practice Address - Street 2:
Practice Address - City:THOMPSON FALLS
Practice Address - State:MT
Practice Address - Zip Code:59873-0969
Practice Address - Country:US
Practice Address - Phone:406-827-4307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6022207Q00000X
MT439363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTC64249Medicare UPIN
MTQ61708Medicare UPIN
MT0083257Medicare ID - Type UnspecifiedCORPORATION MEDICARE #