Provider Demographics
NPI:1023188943
Name:JENNINGS ORTHOPEDIC INC
Entity Type:Organization
Organization Name:JENNINGS ORTHOPEDIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:951-352-2029
Mailing Address - Street 1:10683 MAGNOLIA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1893
Mailing Address - Country:US
Mailing Address - Phone:951-352-2029
Mailing Address - Fax:951-352-2549
Practice Address - Street 1:10683 MAGNOLIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1893
Practice Address - Country:US
Practice Address - Phone:951-352-2029
Practice Address - Fax:951-352-2549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO02544222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000030Medicaid
CAGXC000030Medicaid