MEDICARE: JENCO MEDICAL INCORPORATED DBA SAMOA PROSTHETICS ORTHOTICS COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	00324	AS

General Provider Information

NPI Number	:	1821455981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENCO MEDICAL INCORPORATED DBA SAMOA PROSTHETICS ORTHOTICS COMPANY

Provider Business Mailing Address
First Line	:	356 E 600 S
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-3949
Country	:	US
Telephone Number	:	435-688-9338
Fax Number	:	435-673-3747

Provider Business Practice Location Address
First Line	:	5958 LITANI SQ
Second Line	:	NUU'ULI VILLAGE
City	:	PAGO PAGO
State	:	AS
Zip	:	96799
Country	:	US
Telephone Number	:	684-699-0362
Fax Number	:

Authorized Official
Title or Position	:	EXECTIVE DIRECTOR/OWNER
Name	:	MR. MATTHEW BRACKEN
Credential	:	CPO
Telephone Number	:	801-455-9300

Provider Enumeration Date	:	01/20/2016
Last Update Date	:	01/20/2016

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