Basic Information
| Provider Information | |||||||||
| NPI: | 1750500237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANITE WELLNESS CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY RECOVERY RESOURCES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| 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: | 180 SIERRA COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302739541 | ||||||||
| FaxNumber: | 5302737740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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 | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 251S00000X | 290002AN | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 29AA | 01 | CA | DRUG MEDI-CAL | OTHER |