Provider Demographics
NPI:1578389946
Name:612 MASH INCORPORATED
Entity type:Organization
Organization Name:612 MASH INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MABLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-774-8694
Mailing Address - Street 1:730 E 38TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 E 38TH ST STE 100
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-5218
Practice Address - Country:US
Practice Address - Phone:612-598-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center