Healthcare Provider Details

I. General information

NPI: 1255526042
Provider Name (Legal Business Name): GRANITE WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SUNRISE AVE STE 100
ROSEVILLE CA
95661-4106
US

IV. Provider business mailing address

406 SUNRISE AVE STE 100
ROSEVILLE CA
95661-4106
US

V. Phone/Fax

Practice location:
  • Phone: 916-782-3737
  • Fax: 916-782-3739
Mailing address:
  • Phone: 916-872-1517
  • Fax: 916-797-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number310019EN
License Number StateCA

VIII. Authorized Official

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