Healthcare Provider Details

I. General information

NPI: 1275140022
Provider Name (Legal Business Name): MOSAIC ORTHOTICS AND PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 N 17TH ST # 102
COLORADO SPRINGS CO
80904-3577
US

IV. Provider business mailing address

6305 MONTARBOR DR
COLORADO SPRINGS CO
80918-4875
US

V. Phone/Fax

Practice location:
  • Phone: 719-271-5857
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN MOORE
Title or Position: CERTIFIED PROSTHETIST ORTHOTIST
Credential: CPO
Phone: 719-231-7893