Provider Demographics
NPI:1548479801
Name:MOSAIC PRIME
Entity type:Organization
Organization Name:MOSAIC PRIME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-568-6009
Mailing Address - Street 1:1318 MARSH CREEK LN
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-3940
Mailing Address - Country:US
Mailing Address - Phone:901-568-6009
Mailing Address - Fax:866-359-8798
Practice Address - Street 1:20 DUDLEY ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-4904
Practice Address - Country:US
Practice Address - Phone:901-866-1655
Practice Address - Fax:866-359-8798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44D1053242291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44D1053242OtherCLIA CERTIFICATION LAB