Basic Information
Provider Information | |||||||||
NPI: | 1285860403 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRANITE WELLNESS CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY RECOVERY RESOURCES | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6028 | ||||||||
Address2: |   | ||||||||
City: | AUBURN | ||||||||
State: | CA | ||||||||
PostalCode: | 956046028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308785166 | ||||||||
FaxNumber: | 9167978979 | ||||||||
Practice Location | |||||||||
Address1: | 159 BRENTWOOD DR | ||||||||
Address2: |   | ||||||||
City: | GRASS VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 959455703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302739541 | ||||||||
FaxNumber: | 5302717036 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2009 | ||||||||
LastUpdateDate: | 09/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EBBERT | ||||||||
AuthorizedOfficialFirstName: | ELAINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OPERATIONS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5308785166 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 290002BN | CA | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
No ID Information.