Provider Demographics
NPI:1568084333
Name:GREAT LAKES ADDICTION RECOVERY SERVICES PLLC
Entity Type:Organization
Organization Name:GREAT LAKES ADDICTION RECOVERY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-306-2244
Mailing Address - Street 1:142 E MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2735
Mailing Address - Country:US
Mailing Address - Phone:517-306-2244
Mailing Address - Fax:866-465-0269
Practice Address - Street 1:142 E MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2735
Practice Address - Country:US
Practice Address - Phone:517-306-2244
Practice Address - Fax:866-465-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104719902Medicaid