05D2105279 CLIA NUMBER - BREAKAWAY HEALTH CORPORATION

Laboratory Demographics

CLIA Number: 05D2105279

Facility Name: BREAKAWAY HEALTH CORPORATION

Facility Address:
3151 AIRWAY AVE STE D1
COSTA MESA, CA
ZIP 92626
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Facility Phone Number: 714 957-8229

Facility Type: Comp. Outpatient Rehab Facility

Certificate Type: Waiver

NPI Number: 1851474225

Taxonomy: 261QR0401X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D2105279
LAB Type	Comp. Outpatient Rehab Facility
Facility Name	BREAKAWAY HEALTH CORPORATION
Street	3151 AIRWAY AVE STE D1
City	COSTA MESA
State	CA
ZIP	92626
Phone	714 957-8229
CertificateType	4
CertificateEffectiveDate	11/23/2023
CertificateExpirationDate	11/22/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024