Provider Demographics
NPI:1235329053
Name:MISSOURI BREAKS MEDICAL
Entity Type:Organization
Organization Name:MISSOURI BREAKS MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-964-3418
Mailing Address - Street 1:HC 64 BOX 52
Mailing Address - Street 2:
Mailing Address - City:TIMBER LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57656-9740
Mailing Address - Country:US
Mailing Address - Phone:605-964-3418
Mailing Address - Fax:605-934-3415
Practice Address - Street 1:HC 64 BOX 52
Practice Address - Street 2:
Practice Address - City:TIMBER LAKE
Practice Address - State:SD
Practice Address - Zip Code:57656-9740
Practice Address - Country:US
Practice Address - Phone:605-964-3418
Practice Address - Fax:605-934-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center