Provider Demographics
NPI:1255505806
Name:GRAHAM, BOB GENE
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:GENE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 TEE LN
Mailing Address - Street 2:
Mailing Address - City:BABSON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33827-9501
Mailing Address - Country:US
Mailing Address - Phone:863-638-2866
Mailing Address - Fax:863-638-4090
Practice Address - Street 1:106 TEE LN
Practice Address - Street 2:
Practice Address - City:BABSON PARK
Practice Address - State:FL
Practice Address - Zip Code:33827-9501
Practice Address - Country:US
Practice Address - Phone:863-638-2866
Practice Address - Fax:863-638-4090
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency