Healthcare Provider Details

I. General information

NPI: 1518022763
Provider Name (Legal Business Name): GRANITE BAY CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 FOREST AVE
PORTLAND ME
04103-3396
US

IV. Provider business mailing address

5 WARREN ST
CONCORD NH
03301-4044
US

V. Phone/Fax

Practice location:
  • Phone: 207-878-3229
  • Fax: 207-797-3018
Mailing address:
  • Phone: 603-224-0044
  • Fax: 603-225-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. KASAI MUMPINI
Title or Position: PRESIDENT & CEO
Credential: MBA
Phone: 603-224-0044