Provider Demographics
NPI:1518349034
Name:BREAKAWAY IOP LLC
Entity Type:Organization
Organization Name:BREAKAWAY IOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:BRAXTON
Authorized Official - Last Name:JEFFERYS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:828-273-1643
Mailing Address - Street 1:213 MEADOW RUN EXT
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-9787
Mailing Address - Country:US
Mailing Address - Phone:828-707-0250
Mailing Address - Fax:
Practice Address - Street 1:7 BEAVERDAM RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-6626
Practice Address - Country:US
Practice Address - Phone:828-707-0250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health