Provider Demographics
NPI:1194910430
Name:MOSAIC INC
Entity type:Organization
Organization Name:MOSAIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:406-388-4988
Mailing Address - Street 1:11 W MAIN ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-3700
Mailing Address - Country:US
Mailing Address - Phone:406-388-4988
Mailing Address - Fax:406-388-6188
Practice Address - Street 1:11 W MAIN ST
Practice Address - Street 2:SUITE 218
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-3700
Practice Address - Country:US
Practice Address - Phone:406-388-4988
Practice Address - Fax:406-388-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9393261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1407171507OtherCLINIC NPI