Healthcare Provider Details

I. General information

NPI: 1518184621
Provider Name (Legal Business Name): GRANITE WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

IV. Provider business mailing address

PO BOX 6028
AUBURN CA
95604-6028
US

V. Phone/Fax

Practice location:
  • Phone: 530-885-1917
  • Fax: 530-885-1169
Mailing address:
  • Phone: 530-878-5166
  • Fax: 916-797-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number310019BN
License Number StateCA

VIII. Authorized Official

Name: ELAINE EBBERT
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 530-878-5166