Provider Demographics
NPI:1376747709
Name:GRANITE WELLNESS CENTERS
Entity Type:Organization
Organization Name:GRANITE WELLNESS CENTERS
Other - Org Name:LINCOLN SERVICE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-878-5166
Mailing Address - Street 1:PO BOX 6028
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95604-6028
Mailing Address - Country:US
Mailing Address - Phone:530-878-5166
Mailing Address - Fax:916-797-8979
Practice Address - Street 1:1530 3RD ST STE 106
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-2500
Practice Address - Country:US
Practice Address - Phone:916-434-8927
Practice Address - Fax:916-434-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310019CN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31AAOtherDRUG MEDI-CAL
CA310001 CNOtherDEPT OF ALCOHOL & DRUG PR