Provider Demographics
NPI:1821136813
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 1:5191 S BRYANT BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-9561
Practice Address - Country:US
Practice Address - Phone:325-651-3333
Practice Address - Fax:325-651-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX315P00000X, 320900000X, 385HR2060X, 385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Not Answered385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child