Provider Demographics
NPI:1497376735
Name:GREAT LAKES RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GUARDIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:419-680-0172
Mailing Address - Street 1:441 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:44836-9689
Mailing Address - Country:US
Mailing Address - Phone:419-269-7740
Mailing Address - Fax:
Practice Address - Street 1:2575 HAYES AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-5201
Practice Address - Country:US
Practice Address - Phone:567-280-9435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility