Provider Demographics
NPI:1821455981
Name:JENCO MEDICAL INCORPORATED DBA SAMOA PROSTHETICS ORTHOTICS COMPANY
Entity Type:Organization
Organization Name:JENCO MEDICAL INCORPORATED DBA SAMOA PROSTHETICS ORTHOTICS COMPANY
Other - Org Name:SAMOA PROSTHETICS ORTHOTICS COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECTIVE DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:801-455-9300
Mailing Address - Street 1:356 E 600 S
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3949
Mailing Address - Country:US
Mailing Address - Phone:435-688-9338
Mailing Address - Fax:435-673-3747
Practice Address - Street 1:5958 LITANI SQ
Practice Address - Street 2:NUU'ULI VILLAGE
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799
Practice Address - Country:US
Practice Address - Phone:684-699-0362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS00324332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies