Basic Information
| Provider Information | |||||||||
| NPI: | 1912333774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACEMED HEALTH CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRACEMED EVERGREEN FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 N TOPEKA ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168662000 | ||||||||
| FaxNumber: | 3168662084 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 W 26TH ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672045102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168662000 | ||||||||
| FaxNumber: | 3168662084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | VENUS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3168662064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRACEMED HEALTH CLINIC, INC | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.