Provider Demographics
NPI:1174716948
Name:THE STATION BREAK
Entity type:Organization
Organization Name:THE STATION BREAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LYBARGER-DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-397-3841
Mailing Address - Street 1:501 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-4194
Mailing Address - Country:US
Mailing Address - Phone:740-397-3841
Mailing Address - Fax:740-392-7054
Practice Address - Street 1:501 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-4194
Practice Address - Country:US
Practice Address - Phone:740-397-3841
Practice Address - Fax:740-392-7054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)