Provider Demographics
NPI:1760626311
Name:GREAT LAKES RECOVERY CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:TOUTANT
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:906-228-9699
Mailing Address - Street 1:97 S FOURTH ST. SUITE C
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:906-228-0505
Practice Address - Street 1:100 MALTON RD
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-2001
Practice Address - Country:US
Practice Address - Phone:906-485-2347
Practice Address - Fax:906-486-1150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES RECOVERY CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-27
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
MI520072261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3272541Medicaid