Provider Demographics
NPI:1699543777
Name:LAKE HURON CENTER LLC
Entity type:Organization
Organization Name:LAKE HURON CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERROLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTUSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-743-0396
Mailing Address - Street 1:2870 E GRAND BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3120
Mailing Address - Country:US
Mailing Address - Phone:313-736-5041
Mailing Address - Fax:
Practice Address - Street 1:2870 E GRAND BLVD STE 600
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3120
Practice Address - Country:US
Practice Address - Phone:313-736-5041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty