Provider Demographics
NPI:1518268887
Name:JASON LOVELL
Entity Type:Organization
Organization Name:JASON LOVELL
Other - Org Name:RIVERTON FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-856-4969
Mailing Address - Street 1:PO BOX 1783
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0235
Mailing Address - Country:US
Mailing Address - Phone:801-253-4103
Mailing Address - Fax:801-253-0942
Practice Address - Street 1:716 COLLEGE VIEW DR
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2282
Practice Address - Country:US
Practice Address - Phone:307-857-4969
Practice Address - Fax:307-856-3883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7960A207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1518268887Medicaid
WY1518268887Medicaid