1639217862 NPI number — JENCO MEDICAL, INC.

Table of content: (NPI 1639217862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639217862 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:
Provider Other Organization Name Type Code:
6
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:
1639217862
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:
7026 COMMERCE PARK DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MIDVALE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84047-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-566-5795
Provider Business Practice Location Address Fax Number:
801-566-5790
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRACKEN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
801-566-5795

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  E99607 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 870299464008 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103002163101 . This is a "SELECTHEALTH IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 199033 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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