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General NPI Number Information
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NPI Number | 1700055209
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Entity Type | Organization
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Legal Business Name | BREAKAWAY, INC
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Dates
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Enumeration Date | 02/28/2008
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Last Update Date | 11/30/2011
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Provider Practice Location Address
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Address Line | 106 E 39TH ST
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City | GARDEN CITY
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State | ID
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Zip | 83714-6440
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Country | US
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Telephone | 208-342-4506
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Fax | 208-342-4507
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Provider Business Mailing Address
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Address Line | PO BOX 1593
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City | BOISE
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State | ID
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Zip | 83701-1593
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Country | US
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Telephone | 208-342-4506
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Fax | 208-342-4507
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | MRS. CAROL C ELLIOTT
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Credential |
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Telephone | 208-342-4506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 047307
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License Number State | ID
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