Healthcare Provider Details

I. General information

NPI: 1568937647
Provider Name (Legal Business Name): BREAKTHROUGH MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114B HOSPITAL DR
SIMPSONVILLE SC
29681-3226
US

IV. Provider business mailing address

114B HOSPITAL DR
SIMPSONVILLE SC
29681-3226
US

V. Phone/Fax

Practice location:
  • Phone: 864-757-8561
  • Fax: 864-757-9474
Mailing address:
  • Phone: 864-757-8561
  • Fax: 864-757-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LAURA FRANCIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 864-757-8561