Provider Demographics
NPI:1639751373
Name:BREAKAWAY DETOX CENTERS
Entity Type:Organization
Organization Name:BREAKAWAY DETOX CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PLASKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-957-8229
Mailing Address - Street 1:3151 AIRWAY AVE STE D1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4622
Mailing Address - Country:US
Mailing Address - Phone:714-957-8229
Mailing Address - Fax:
Practice Address - Street 1:18779 PALM ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6428
Practice Address - Country:US
Practice Address - Phone:714-916-0219
Practice Address - Fax:714-369-2577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREAKAWAY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility