Healthcare Provider Details

I. General information

NPI: 1730830365
Provider Name (Legal Business Name): MOSAIC MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NE A ST STE 101
MADRAS OR
97741-1842
US

IV. Provider business mailing address

600 SW COLUMBIA ST STE 6150
BEND OR
97702-1099
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-3005
  • Fax: 541-383-1883
Mailing address:
  • Phone: 541-383-3005
  • Fax: 541-383-1883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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