Provider Demographics
NPI:1518022763
Name:GRANITE BAY CARE, INC
Entity Type:Organization
Organization Name:GRANITE BAY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KASAI
Authorized Official - Middle Name:
Authorized Official - Last Name:MUMPINI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:603-224-0044
Mailing Address - Street 1:5 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-4044
Mailing Address - Country:US
Mailing Address - Phone:603-224-0044
Mailing Address - Fax:603-225-1175
Practice Address - Street 1:1037 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3396
Practice Address - Country:US
Practice Address - Phone:207-878-3229
Practice Address - Fax:207-797-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME417080000Medicaid