Provider Demographics
NPI:1497019111
Name:BREAKWATER MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:BREAKWATER MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCHINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-533-4220
Mailing Address - Street 1:357 VICTORIA ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1931
Mailing Address - Country:US
Mailing Address - Phone:949-903-1053
Mailing Address - Fax:877-820-8959
Practice Address - Street 1:357 VICTORIA ST
Practice Address - Street 2:SUITE 2
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1931
Practice Address - Country:US
Practice Address - Phone:949-903-1053
Practice Address - Fax:877-820-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D2040895291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory