Provider Demographics
NPI:1588016422
Name:MOSAIC COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:MOSAIC COMMUNITY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:410-453-9553
Mailing Address - Street 1:1925 GREENSPRING DR
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4128
Mailing Address - Country:US
Mailing Address - Phone:410-453-9553
Mailing Address - Fax:443-612-1436
Practice Address - Street 1:234 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-2405
Practice Address - Country:US
Practice Address - Phone:410-675-4704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-03
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMH-2044261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMH-2044OtherDHMH LICENSE