1104047430 NPI number — JENCO MEDICAL, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104047430 NPI number — JENCO MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENCO MEDICAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UTAH PROSTHETICS AND ORTHOTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104047430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7026 COMMERCE PARK DR
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MIDVALE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84047-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-566-5795
Provider Business Mailing Address Fax Number:
801-566-5790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1153 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B140
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-750-6579
Provider Business Practice Location Address Fax Number:
435-750-6586
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHILDS
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
COLLEEN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
801-566-5795

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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