Provider Demographics
NPI:1679714083
Name:GREAT LAKES RECOVERY CENTERS
Entity type:Organization
Organization Name:GREAT LAKES RECOVERY CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOUTANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-228-9699
Mailing Address - Street 1:100 MALTON RD
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866-2001
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:906-228-0505
Practice Address - Street 1:1101 LUDINGTON ST. SUITE H
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829
Practice Address - Country:US
Practice Address - Phone:906-789-3528
Practice Address - Fax:906-786-9801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES RECOVERY CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-13
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI210024261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3272541Medicaid