Provider Demographics
NPI:1407818602
Name:MAST CLINIC INC
Entity Type:Organization
Organization Name:MAST CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:207-321-9027
Mailing Address - Street 1:94 RACKLEFF ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-321-9027
Mailing Address - Fax:207-747-4107
Practice Address - Street 1:980 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3388
Practice Address - Country:US
Practice Address - Phone:207-321-9027
Practice Address - Fax:207-747-4107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME12403000Medicaid
ME336900099Medicaid
11364602OtherCAQH