=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912277864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANITE WELLNESS CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2012
-----------------------------------------------------
Last Update Date | 09/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8491 NORTH LAKE BLVD.
-----------------------------------------------------
City | KINGS BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-546-5641
-----------------------------------------------------
Fax | 530-546-5480
-----------------------------------------------------
=====================================================
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 | ADMINISTRATIVE ASSOCIATE
-----------------------------------------------------
Name | KARYN RUBICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-878-5166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------