Provider Demographics
NPI:1174663801
Name:MOSAIC
Entity Type:Organization
Organization Name:MOSAIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
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 1:217 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:IA
Practice Address - Zip Code:51546-1348
Practice Address - Country:US
Practice Address - Phone:712-644-2378
Practice Address - Fax:712-664-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2439232320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness