=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750500237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANITE WELLNESS CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 09/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 SIERRA COLLEGE DR
-----------------------------------------------------
City | GRASS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95945-5768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-273-9541
-----------------------------------------------------
Fax | 530-273-7740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6028
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95604-6028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-878-5166
-----------------------------------------------------
Fax | 916-797-8979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS DIRECTOR
-----------------------------------------------------
Name | ELAINE EBBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-878-5166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 290002AN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------