Provider Demographics
NPI:1265075279
Name:MAST ENTERPRISES
Entity type:Organization
Organization Name:MAST ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTANTUONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-219-1988
Mailing Address - Street 1:40800 FIVE MILE RD STE C
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40800 FIVE MILE RD STE C
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-293-1340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI19282071032Medicaid