Provider Demographics
NPI:1639834013
Name:MOSAIC MEDICAL MASSAGE, LLC
Entity Type:Organization
Organization Name:MOSAIC MEDICAL MASSAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - CEO
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:JANE ENNIS
Authorized Official - Last Name:ALBRIGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:307-922-1477
Mailing Address - Street 1:PO BOX 971
Mailing Address - Street 2:
Mailing Address - City:INDIAN HILLS
Mailing Address - State:CO
Mailing Address - Zip Code:80454-0971
Mailing Address - Country:US
Mailing Address - Phone:307-922-1477
Mailing Address - Fax:
Practice Address - Street 1:5346 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:INDIAN HILLS
Practice Address - State:CO
Practice Address - Zip Code:80454-5033
Practice Address - Country:US
Practice Address - Phone:307-922-1477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty