Breakwater Medical Group LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

05D2040895 Issued in CA

Legal business name

BREAKWATER MEDICAL GROUP LLC

Practice address

357 Victoria St
Suite 2
Costa Mesa, CA 92627-1931

Phone

(949) 903-1053

Fax

(877) 820-8959

NPI assigned

Jun 27, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Matt Luchini

Title

Accounts Manager

Phone

(928) 533-4220

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1340755200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1340755200000",
    "number": "1497019111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "357 VICTORIA ST",
            "address_2": "SUITE 2",
            "city": "COSTA MESA",
            "state": "CA",
            "postal_code": "926271931",
            "telephone_number": "949-903-1053",
            "fax_number": "877-820-8959"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "357 VICTORIA ST",
            "address_2": "SUITE 2",
            "city": "COSTA MESA",
            "state": "CA",
            "postal_code": "926271931",
            "telephone_number": "949-903-1053",
            "fax_number": "877-820-8959"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREAKWATER MEDICAL GROUP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-06-27",
        "last_updated": "2012-06-27",
        "status": "A",
        "authorized_official_last_name": "LUCHINI",
        "authorized_official_first_name": "MATT",
        "authorized_official_title_or_position": "ACCOUNTS MANAGER",
        "authorized_official_telephone_number": "928-533-4220"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "CA",
            "license": "05D2040895",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Peggy Delong Branson, N.D.
• Autumn Reece Brant
• Bryan Brant
• Navjot Brar
• Breakaway Health Corporation
• Breakwater Recovery, LLC
• Patricia Brewer
• Scott Briggs
• Swantee Lashon Briggs
• Brighter Days MHC LLC

• Clinical Medical Laboratory in Costa Mesa, CA
• Providers in Costa Mesa, CA by specialty
• Clinical Medical Laboratory in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.