Provider Demographics
NPI:1578600235
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 1:2170 BUSINESS CENTER DR
Practice Address - Street 2:SUITE 6
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-5626
Practice Address - Country:US
Practice Address - Phone:901-372-6100
Practice Address - Fax:901-372-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPS0000000050OtherSKILLED NURSING
TNL3204M30466177OtherMR ADULT HAB SUPP LIVING