1063171593 NPI number — GREAT LAKES RECOVERY MISSION, LLC

Table of content: (NPI 1063171593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063171593 NPI number — GREAT LAKES RECOVERY MISSION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES RECOVERY MISSION, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063171593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5099 W FARRAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLIO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48420-8215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-491-1057
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 W 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48503-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-275-2690
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BUKOFFSKY
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
586-491-1057

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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