1518022763 NPI number — GRANITE BAY CARE, INC

Table of content: (NPI 1518022763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518022763 NPI number — GRANITE BAY CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANITE BAY CARE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518022763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 WARREN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03301-4044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-224-0044
Provider Business Mailing Address Fax Number:
603-225-1175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1037 FOREST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04103-3396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-878-3229
Provider Business Practice Location Address Fax Number:
207-797-3018
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUMPINI
Authorized Official First Name:
KASAI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
603-224-0044

Provider Taxonomy Codes

  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 417080000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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