Healthcare Provider Details

I. General information

NPI: 1376747709
Provider Name (Legal Business Name): GRANITE WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 3RD ST STE 106
LINCOLN CA
95648-2500
US

IV. Provider business mailing address

PO BOX 6028
AUBURN CA
95604-6028
US

V. Phone/Fax

Practice location:
  • Phone: 916-434-8927
  • Fax: 916-434-0678
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 Number310019CN
License Number StateCA

VIII. Authorized Official

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