Healthcare Provider Details

I. General information

NPI: 1184273757
Provider Name (Legal Business Name): MOSAIC COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 04/20/2023
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 NE TUCSON WAY APT 110
BEND OR
97701-5182
US

IV. Provider business mailing address

600 SW COLUMBIA ST STE 6210
BEND OR
97702-1099
US

V. Phone/Fax

Practice location:
  • Phone: 541-408-9486
  • Fax: 541-647-2793
Mailing address:
  • Phone: 541-408-9486
  • Fax: 541-647-2793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: BOBBI JOLYNE SURPLUS
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 541-408-9486