Provider Demographics
NPI:1134712417
Name:BREAKTHROUGH OUTBREAKING OUTREACH MINISTRY
Entity type:Organization
Organization Name:BREAKTHROUGH OUTBREAKING OUTREACH MINISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALDARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-748-6991
Mailing Address - Street 1:7653 BRANCHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5801
Mailing Address - Country:US
Mailing Address - Phone:910-748-6991
Mailing Address - Fax:
Practice Address - Street 1:7653 BRANCHWOOD CIR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-5801
Practice Address - Country:US
Practice Address - Phone:910-748-6991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No174200000XOther Service ProvidersMeals
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNAMedicaid