Provider Demographics
NPI:1275043770
Name:GRANITE RIDGE HOME HEALTH NURSING CARE, INC.
Entity Type:Organization
Organization Name:GRANITE RIDGE HOME HEALTH NURSING CARE, INC.
Other - Org Name:GRANITE RIDGE HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:559-977-3952
Mailing Address - Street 1:35300 HIGHWAY 41 STE 201
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-8717
Mailing Address - Country:US
Mailing Address - Phone:559-977-3952
Mailing Address - Fax:559-420-0310
Practice Address - Street 1:35300 HIGHWAY 41 STE 201
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-8717
Practice Address - Country:US
Practice Address - Phone:559-977-3952
Practice Address - Fax:559-420-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA789398163WE0003X, 163WH1000X, 163WI0500X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Multi-Specialty
No163WH1000XNursing Service ProvidersRegistered NurseHospiceGroup - Multi-Specialty
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275043770Medicaid