1548479801 NPI number — MOSAIC PRIME

Table of content: (NPI 1548479801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548479801 NPI number — MOSAIC PRIME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSAIC PRIME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548479801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1318 MARSH CREEK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLIERVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38017-3940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-568-6009
Provider Business Mailing Address Fax Number:
866-359-8798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 DUDLEY ST
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38103-4904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-866-1655
Provider Business Practice Location Address Fax Number:
866-359-8798
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAHL
Authorized Official First Name:
JULIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
901-568-6009

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  44D1053242 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 44D1053242 . This is a "CLIA CERTIFICATION LAB" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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