Provider Demographics
NPI:1033864954
Name:GREAT LAKES RECOVERY CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTERS
Other - Org Name:GLRC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:TOUTANT
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:906-228-9699
Mailing Address - Street 1:97 S 4TH ST SUITE C
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2168
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:906-228-0505
Practice Address - Street 1:100 MALTON RD SUITE 7 & SUITE 8
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866
Practice Address - Country:US
Practice Address - Phone:906-464-0002
Practice Address - Fax:906-464-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty