Basic Information
| Provider Information | |||||||||
| NPI: | 1518626035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES RECOVERY MISSION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5099 W FARRAND RD | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484208215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864911057 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 N GRAND TRAVERSE ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102752690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2021 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | BUKOFFSKY | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5864911057 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREAT LAKES RECOVERY MISSION, LLC | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.