Basic Information
| Provider Information | |||||||||
| NPI: | 1376747709 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANITE WELLNESS CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LINCOLN SERVICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 1530 3RD ST STE 106 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956482500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164348927 | ||||||||
| FaxNumber: | 9164340678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EBBERT | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5308785166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 310019CN | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 31AA | 01 | CA | DRUG MEDI-CAL | OTHER |