Provider Demographics
NPI:1790558286
Name:GREAT LAKES RECOVERY CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTERS
Other - Org Name:TEAL LAKE WOMEN'S RESIDENTIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:URIAS
Authorized Official - Last Name:GIUCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-228-9699
Mailing Address - Street 1:97 S 4TH ST
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:888-977-2109
Practice Address - Street 1:100 MALTON RD STE 1
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-2002
Practice Address - Country:US
Practice Address - Phone:906-451-4889
Practice Address - Fax:906-228-8156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES RECOVERY CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-06
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
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