Healthcare Provider Details

I. General information

NPI: 1962685263
Provider Name (Legal Business Name): GRANITE HARBOR BUSINESS DEVELOPMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JAMES P. MURPHY INDUSTRIAL HIGHWAY
WEST WARWICK RI
02893
US

IV. Provider business mailing address

PO BOX 7782
WARWICK RI
02887-7782
US

V. Phone/Fax

Practice location:
  • Phone: 401-615-5538
  • Fax: 401-615-8137
Mailing address:
  • Phone: 603-867-8003
  • Fax: 401-615-8137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY MCCARTHY
Title or Position: MANAGER
Credential:
Phone: 603-867-8003