Healthcare Provider Details

I. General information

NPI: 1912277864
Provider Name (Legal Business Name): GRANITE WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8491 NORTH LAKE BLVD.
KINGS BEACH CA
96143
US

IV. Provider business mailing address

PO BOX 6028
AUBURN CA
95604-6028
US

V. Phone/Fax

Practice location:
  • Phone: 530-546-5641
  • Fax: 530-546-5480
Mailing address:
  • Phone: 530-878-5166
  • Fax: 916-797-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KARYN RUBICK
Title or Position: ADMINISTRATIVE ASSOCIATE
Credential:
Phone: 530-878-5166