Provider Demographics
NPI:1134439151
Name:MAST CLINIC, INC
Entity type:Organization
Organization Name:MAST CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:PT MSED
Authorized Official - Phone:207-892-5328
Mailing Address - Street 1:94 RACKLEFF ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3054
Mailing Address - Country:US
Mailing Address - Phone:207-892-5328
Mailing Address - Fax:
Practice Address - Street 1:1 WESTBROOK CMN
Practice Address - Street 2:SUITE 2
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2804
Practice Address - Country:US
Practice Address - Phone:207-892-5328
Practice Address - Fax:866-416-3820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT677252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency