Provider Demographics
NPI:1699754143
Name:MISSOURI BREAKS INDUSTRIES RESEARCH, INC.
Entity type:Organization
Organization Name:MISSOURI BREAKS INDUSTRIES RESEARCH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-964-3418
Mailing Address - Street 1:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-1824
Mailing Address - Country:US
Mailing Address - Phone:605-964-3418
Mailing Address - Fax:605-964-3415
Practice Address - Street 1:118 S WILLOW ST
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-3418
Practice Address - Fax:605-964-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9218369OtherDAKOTA CARE
SD9161950Medicaid
SD4995628OtherBLUECROSS/BLUESHIELD
SD=========OtherNTCA
SD4995628OtherBLUECROSS/BLUESHIELD
SD=========Other1ST AMERICAN ADMINISTRAT
SD=========OtherTRI-CARE
SD=========OtherMAIL HANDLERS
SD9218369OtherDAKOTA CARE