Organization
BREAKAWAY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CAROL C ELLIOTT (VICE-PRESIDENT)
(208) 342-4506
Entity
Organization
Contact information
Practice address
106 E 39TH ST, GARDEN CITY, ID 83714-6440
(208) 342-4506
(208) 342-4507
Mailing address
PO BOX 1593, BOISE, ID 83701-1593
(208) 342-4506
(208) 342-4507
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
047307
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8061158
—
ID
Enumeration date
02/28/2008
Last updated
11/30/2011
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