Provider Demographics
NPI:1376181149
Name:BREAKAWAY, LLC
Entity type:Organization
Organization Name:BREAKAWAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMETSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-475-7713
Mailing Address - Street 1:2021 VANESTA PL STE D
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-0381
Mailing Address - Country:US
Mailing Address - Phone:913-475-7713
Mailing Address - Fax:913-273-2994
Practice Address - Street 1:2023 SW GAGE BLVD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-3339
Practice Address - Country:US
Practice Address - Phone:785-329-5344
Practice Address - Fax:785-329-5625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty