Provider Demographics
NPI:1821267956
Name:GREAT LAKES RECOVERY CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES RECOVERY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:TOUTANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-228-9699
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:906-228-0505
Practice Address - Street 1:220 ROOSELVELT STREET
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938
Practice Address - Country:US
Practice Address - Phone:906-364-7506
Practice Address - Fax:906-364-7508
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES RECOVERY CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-22
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI270032324500000X
MIMI00719324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3272541Medicaid