Provider Demographics
NPI:1588833404
Name:GREAT LAKES RECOVERY CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:TOUTANT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:906-228-9699
Mailing Address - Street 1:97 S 4TH ST STE 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 1:2655 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3711
Practice Address - Country:US
Practice Address - Phone:906-632-9809
Practice Address - Fax:906-632-2370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI170045324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3272541Medicaid