Provider Demographics
NPI:1700055209
Name:BREAKAWAY, INC
Entity Type:Organization
Organization Name:BREAKAWAY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-342-4506
Mailing Address - Street 1:PO BOX 1593
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1593
Mailing Address - Country:US
Mailing Address - Phone:208-342-4506
Mailing Address - Fax:208-342-4507
Practice Address - Street 1:106 E 39TH ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-6440
Practice Address - Country:US
Practice Address - Phone:208-342-4506
Practice Address - Fax:208-342-4507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID047307332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8061158Medicaid