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General NPI Number Information
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NPI Number | 1477919405
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Entity Type | Organization
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Legal Business Name | BREAKING FREE INC.
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Dates
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Enumeration Date | 01/06/2016
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Last Update Date | 04/13/2017
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Provider Practice Location Address
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Address Line | 120 GALE ST
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City | AURORA
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State | IL
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Zip | 60506-5084
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Country | US
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Telephone | 630-897-1003
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Fax | 630-897-1042
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Provider Business Mailing Address
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Address Line | 120 GALE STREET
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City | AURORA
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State | IL
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Zip | 60506-5084
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Country | US
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Telephone | 630-897-1003
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Fax | 630-897-1042
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Authorized Official
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Title or Position | MANAGER, REVENUE CYCLE
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Name | MR. DIMITRIUS R. MAYO
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Credential |
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Telephone | 630-572-0556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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