Provider Demographics
NPI:1851474225
Name:BREAKAWAY HEALTH CORPORATION
Entity Type:Organization
Organization Name:BREAKAWAY HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PLASKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS, FORENSIC
Authorized Official - Phone:714-957-8229
Mailing Address - Street 1:28251 MILLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1214
Mailing Address - Country:US
Mailing Address - Phone:714-292-0707
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:D-1
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:714-957-8229
Practice Address - Fax:714-957-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300065A101YA0400X
261QM0801X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicare UPIN