Provider Demographics
NPI:1750791505
Name:WALLOON LAKE RECOVERY LODGE, LLC
Entity type:Organization
Organization Name:WALLOON LAKE RECOVERY LODGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:WURST
Authorized Official - Suffix:
Authorized Official - Credentials:RMA
Authorized Official - Phone:231-758-4566
Mailing Address - Street 1:2329 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49713-9268
Mailing Address - Country:US
Mailing Address - Phone:231-535-2822
Mailing Address - Fax:231-535-2372
Practice Address - Street 1:2329 CENTER ST
Practice Address - Street 2:
Practice Address - City:BOYNE FALLS
Practice Address - State:MI
Practice Address - Zip Code:49713-9268
Practice Address - Country:US
Practice Address - Phone:231-535-2822
Practice Address - Fax:231-535-2372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISA0150024OtherLARA LICENSE
MISA0690033OtherLARA LICENSE
MISA0240041OtherLARA LICENSE
MI5801000334OtherTRANSPORTATION
MISA0150031OtherLARA LICENSE