Provider Demographics
NPI:1134513765
Name:MOSAIC COMMUNITY SERVICES, LLC
Entity Type:Organization
Organization Name:MOSAIC COMMUNITY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:PARK
Authorized Official - Last Name:HARTZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-225-7614
Mailing Address - Street 1:602 MATTHEWS AVE
Mailing Address - Street 2:P.O. BOX 1522
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-3259
Mailing Address - Country:US
Mailing Address - Phone:573-621-5160
Mailing Address - Fax:573-621-5161
Practice Address - Street 1:602 MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3259
Practice Address - Country:US
Practice Address - Phone:573-621-5160
Practice Address - Fax:573-621-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO320900000XMedicaid