Basic Information
| Provider Information | |||||||||
| NPI: | 1235644071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANITE WELLNESS CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY RECOVERY RESOURCES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6028 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956046028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308785166 | ||||||||
| FaxNumber: | 9167978979 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 BOST AVE | ||||||||
| Address2: | |||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959593249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308785166 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EBBERT | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5308785166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 290002IN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.