Provider Demographics
NPI:1790444214
Name:GREAT LAKES RECOVERY MISSION, LLC
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY MISSION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKOFFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-491-1057
Mailing Address - Street 1:5099 W FARRAND RD
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-8215
Mailing Address - Country:US
Mailing Address - Phone:586-491-1057
Mailing Address - Fax:
Practice Address - Street 1:427 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2403
Practice Address - Country:US
Practice Address - Phone:810-275-2690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES RECOVERY MISSION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility