Provider Demographics
NPI:1154478857
Name:MOSAIC
Entity Type:Organization
Organization Name:MOSAIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP & CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-896-3884
Mailing Address - Street 1:4980 S 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2220
Mailing Address - Country:US
Mailing Address - Phone:402-896-3884
Mailing Address - Fax:402-894-4780
Practice Address - Street 1:12 E MAIN
Practice Address - Street 2:SUITE 102
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172
Practice Address - Country:US
Practice Address - Phone:563-568-3992
Practice Address - Fax:563-568-4789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0439158Medicaid