Provider Demographics
NPI:1962114512
Name:365 BREAKTHROUGH LLC
Entity type:Organization
Organization Name:365 BREAKTHROUGH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHYON
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-440-3150
Mailing Address - Street 1:6641 E BAYWOOD AVE STE B3
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1723
Mailing Address - Country:US
Mailing Address - Phone:602-921-2565
Mailing Address - Fax:
Practice Address - Street 1:6641 E BAYWOOD AVE STE B3
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1723
Practice Address - Country:US
Practice Address - Phone:602-921-2565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty