Basic Information
| Provider Information | |||||||||
| NPI: | 1275179517 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE - MASE MONTICELLO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479602134 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479602134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126451892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | LOWE | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9493566706 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.