Provider Demographics
NPI:1710581467
Name:JENG, SAMBA
Entity Type:Individual
Prefix:
First Name:SAMBA
Middle Name:
Last Name:JENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 DORIS ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-2029
Mailing Address - Country:US
Mailing Address - Phone:907-903-7873
Mailing Address - Fax:
Practice Address - Street 1:3201 DORIS ST UNIT A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99517-2029
Practice Address - Country:US
Practice Address - Phone:907-903-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101248310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility