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General NPI Number Information
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NPI Number | 1376181149
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Entity Type | Organization
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Legal Business Name | BREAKAWAY, LLC
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Dates
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Enumeration Date | 12/12/2019
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Last Update Date | 12/12/2019
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Provider Practice Location Address
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Address Line | 2023 SW GAGE BLVD
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City | TOPEKA
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State | KS
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Zip | 66604-3339
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Country | US
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Telephone | 785-329-5344
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Fax | 785-329-5625
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Provider Business Mailing Address
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Address Line | 2021 VANESTA PL STE D
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City | MANHATTAN
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State | KS
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Zip | 66503-0381
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Country | US
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Telephone | 913-475-7713
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Fax | 913-273-2994
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Authorized Official
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Title or Position | DIRECTOR OF BILLING/CREDENTIALING
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Name | KERRY CLEMETSON
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Credential |
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Telephone | 913-475-7713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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