Healthcare Provider Details

I. General information

NPI: 1134513765
Provider Name (Legal Business Name): MOSAIC COMMUNITY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 MATTHEWS AVE
SIKESTON MO
63801-3259
US

IV. Provider business mailing address

602 MATTHEWS AVE P.O. BOX 1522
SIKESTON MO
63801-3259
US

V. Phone/Fax

Practice location:
  • Phone: 573-621-5160
  • Fax: 573-621-5161
Mailing address:
  • Phone: 573-621-5160
  • Fax: 573-621-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMO

VIII. Authorized Official

Name: MR. BENJAMIN PARK HARTZOG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-225-7614