Healthcare Provider Details

I. General information

NPI: 1902589146
Provider Name (Legal Business Name): BREAKTHROUGH ECLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 W RIO GRANDE DR
BEVERLY HILLS FL
34465-2016
US

IV. Provider business mailing address

6019 W RIO GRANDE DR
BEVERLY HILLS FL
34465-2016
US

V. Phone/Fax

Practice location:
  • Phone: 523-257-8843
  • Fax:
Mailing address:
  • Phone: 523-257-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NATHALIE GRANT
Title or Position: MANAGER
Credential: APRN
Phone: 352-325-7884