Healthcare Provider Details

I. General information

NPI: 1700055209
Provider Name (Legal Business Name): BREAKAWAY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E 39TH ST
GARDEN CITY ID
83714-6440
US

IV. Provider business mailing address

PO BOX 1593
BOISE ID
83701-1593
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-4506
  • Fax: 208-342-4507
Mailing address:
  • Phone: 208-342-4506
  • Fax: 208-342-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number047307
License Number StateID

VIII. Authorized Official

Name: MRS. CAROL C ELLIOTT
Title or Position: VICE-PRESIDENT
Credential:
Phone: 208-342-4506