Organization
WALLOON LAKE RECOVERY LODGE, LLC
Active
Other names
Bear River Outreach, Bear River Health
Organization subpart
No
Provider details
NPI number
Authorized official
JACKIE DEE WURST RMA (FINANCIAL DIRECTOR)
(231) 758-4566
Entity
Organization
Contact information
Practice address
2329 CENTER ST, BOYNE FALLS, MI 49713-9268
(231) 535-2822
(231) 535-2372
Mailing address
2329 CENTER ST, BOYNE FALLS, MI 49713-9268
(231) 535-2822
(231) 535-2372
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
103T00000X
Psychologist
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
343900000X
Non-emergency Medical Transport (VAN)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5801000334
TRANSPORTATION
MI
01
—
SA0150024
LARA LICENSE
MI
01
—
SA0150031
LARA LICENSE
MI
01
—
SA0240041
LARA LICENSE
MI
01
—
SA0690033
LARA LICENSE
MI
Enumeration date
05/02/2014
Last updated
03/25/2024
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