1215106349 NPI number — GREAT LAKES RECOVERY CENTERS

Table of content: (NPI 1215106349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215106349 NPI number — GREAT LAKES RECOVERY CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES RECOVERY CENTERS
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:
1215106349
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MALTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEGAUNEE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49866-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-228-9699
Provider Business Mailing Address Fax Number:
906-228-0505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 S HEMLOCK ST., SUITE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRON MOUNTAIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-774-2561
Provider Business Practice Location Address Fax Number:
906-774-2597
Provider Enumeration Date:
02/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TOUTANT
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
MILES
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
906-228-9699

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  220019 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3272541 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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