Provider Demographics
NPI:1043646870
Name:GRACEMED HEALTH CLINIC, INC
Entity Type:Organization
Organization Name:GRACEMED HEALTH CLINIC, INC
Other - Org Name:GRACEMED DOWNING FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-866-2064
Mailing Address - Street 1:1122 N TOPEKA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2810
Mailing Address - Country:US
Mailing Address - Phone:316-866-2000
Mailing Address - Fax:316-866-2084
Practice Address - Street 1:2201 E 25TH ST N
Practice Address - Street 2:BUILDING 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67219-4714
Practice Address - Country:US
Practice Address - Phone:316-866-2000
Practice Address - Fax:316-866-2084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACEMED HEALTH CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-25
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100212250AMedicaid
KS100212250AMedicaid