Provider Demographics
NPI:1588186092
Name:THE GRANITEVILLE HOUSE OF RECOVERY
Entity Type:Organization
Organization Name:THE GRANITEVILLE HOUSE OF RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-417-5419
Mailing Address - Street 1:5452 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:SWEET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18656-2482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5452 MAIN RD
Practice Address - Street 2:
Practice Address - City:SWEET VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18656-2482
Practice Address - Country:US
Practice Address - Phone:570-417-5419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
PA407066324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility