Healthcare Provider Details

I. General information

NPI: 1962341156
Provider Name (Legal Business Name): GREAT LAKES RECOVERY MISSION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 MASON ST
FLINT MI
48503-2413
US

IV. Provider business mailing address

5099 W FARRAND RD
CLIO MI
48420-8215
US

V. Phone/Fax

Practice location:
  • Phone: 810-487-4676
  • Fax: 810-496-4295
Mailing address:
  • Phone: 810-487-4676
  • Fax: 810-496-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA BUKOFFSKY
Title or Position: CEO
Credential:
Phone: 586-491-1057