Provider Demographics
NPI:1730377789
Name:BREAK OUT LLC
Entity type:Organization
Organization Name:BREAK OUT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARNELLA
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:WARTHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-477-4785
Mailing Address - Street 1:406 MARE CT
Mailing Address - Street 2:
Mailing Address - City:BAHAMA
Mailing Address - State:NC
Mailing Address - Zip Code:27503-9615
Mailing Address - Country:US
Mailing Address - Phone:919-477-4785
Mailing Address - Fax:
Practice Address - Street 1:412 PINELAND AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2911
Practice Address - Country:US
Practice Address - Phone:919-220-2181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC032414320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness