Provider Demographics
NPI:1033711247
Name:BREAKING THE LABELS ADULT SERVICE PROVIDER, LLC
Entity Type:Organization
Organization Name:BREAKING THE LABELS ADULT SERVICE PROVIDER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-890-2308
Mailing Address - Street 1:701 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1008
Mailing Address - Country:US
Mailing Address - Phone:567-890-2308
Mailing Address - Fax:567-890-2310
Practice Address - Street 1:701 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1008
Practice Address - Country:US
Practice Address - Phone:567-890-2308
Practice Address - Fax:567-890-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0403960Medicaid