WALLOON LAKE RECOVERY LODGE LLC NPI 1750791505

NPI Information

NPI: 1750791505
Provider Name: WALLOON LAKE RECOVERY LODGE, LLC

Doing Business As: BEAR RIVER HEALTH

Classification: Substance Abuse Rehabilitation Facility - 324500000X
Entity Type: Organization

CLIA Number: 23D2205571

Address:
2329 CENTER ST
BOYNE FALLS, MI
ZIP 49713
Phone: (231) 535-2822
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WALLOON LAKE RECOVERY LODGE, LLC is a substance abuse rehabilitation facility in Boyne Falls, MI. The provider is a facility or distinct part of a facility that provides a 24 hr therapeutically planned living and rehabilitative intervention environment for the treatment of individuals with disorders in the abuse of drugs, alcohol, and other substances. WALLOON LAKE RECOVERY LODGE, LLC NPI is 1750791505. The provider is registered as an organization entity type and is a multi-specialty group.
The provider Is Doing Business As Bear River Health.

The provider's business location address is:

2329 CENTER ST
BOYNE FALLS, MI
ZIP 49713-268
Phone: (231) 535-2822
Fax: (231) 535-2372

The provider's authorized official is Jackie Dee Wurst .
The authorized official title is Financial Director and has the following contact phone number (231) 758-4566.

The CLIA number assigned to this NPI record is 23D2205571 - comp. outpatient rehab facility with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 5/2/2014 and was last updated on 3/25/2024.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	Primary
1	101Y00000X	Counselor		No
2	103T00000X	Psychologist		No
3	261QR0405X	Clinic/Center	Rehabilitation, Substance Use Disorder	No
4	324500000X	Substance Abuse Rehabilitation Facility		Yes
5	343900000X	Non-emergency Medical Transport (VAN)		No

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	SA0150024	OTHER	MICHIGAN	LARA LICENSE
2	SA0690033	OTHER	MICHIGAN	LARA LICENSE
3	SA0240041	OTHER	MICHIGAN	LARA LICENSE
4	5801000334	OTHER	MICHIGAN	TRANSPORTATION
5	SA0150031	OTHER	MICHIGAN	LARA LICENSE

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

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