Provider Demographics
NPI:1275140022
Name:MOSAIC ORTHOTICS AND PROSTHETICS LLC
Entity Type:Organization
Organization Name:MOSAIC ORTHOTICS AND PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PROSTHETIST ORTHOTIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:719-231-7893
Mailing Address - Street 1:6305 MONTARBOR DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:617 N 17TH ST # 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3577
Practice Address - Country:US
Practice Address - Phone:719-271-5857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier