Provider Demographics
NPI:1275179517
Name:PROACTIVE - MASE MONTICELLO
Entity Type:Organization
Organization Name:PROACTIVE - MASE MONTICELLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-356-6706
Mailing Address - Street 1:303 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-2134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-2134
Practice Address - Country:US
Practice Address - Phone:812-645-1892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care