Provider Demographics
NPI:1588020374
Name:GREAT LAKES RECOVERY CENTER
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SALO
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:906-228-9696
Mailing Address - Street 1:97 S 4TH ST
Mailing Address - Street 2:SUITE C
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:
Practice Address - Street 1:1009 W RIDGE ST
Practice Address - Street 2:SUITE C
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3997
Practice Address - Country:US
Practice Address - Phone:906-228-6545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098960261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder