Healthcare Provider Details

I. General information

NPI: 1497376735
Provider Name (Legal Business Name): GREAT LAKES RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 HAYES AVE
FREMONT OH
43420-5201
US

IV. Provider business mailing address

441 N BROADWAY ST
GREEN SPRINGS OH
44836-9689
US

V. Phone/Fax

Practice location:
  • Phone: 567-280-9435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: DAVID GUARDIOLA
Title or Position: EXECUTIVE DIRECTOR
Credential: LISW-S
Phone: 567-280-9435