Provider Demographics
NPI:1164844791
Name:ORTHO MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:ORTHO MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-528-7350
Mailing Address - Street 1:3480 WASHINGTON BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-4152
Mailing Address - Country:US
Mailing Address - Phone:801-528-7350
Mailing Address - Fax:801-528-7355
Practice Address - Street 1:3480 WASHINGTON BLVD STE 107
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-4152
Practice Address - Country:US
Practice Address - Phone:801-528-7350
Practice Address - Fax:801-528-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13746360-004-STC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13746360OtherUTAH TAX CERTIFICATE