=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205446044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREAKTHROUGH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2020
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2147 UNIVERSITY AVE W
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55114-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-340-6795
-----------------------------------------------------
Fax | 651-202-3166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2147 UNIVERSITY AVE W
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55114-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-340-6795
-----------------------------------------------------
Fax | 651-202-3166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SUKIMO D KNIGHT
-----------------------------------------------------
Credential | LADC
-----------------------------------------------------
Telephone | 612-201-8111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------