Provider Demographics
NPI:1265631840
Name:DANIEL HUFFMAN BOLIN
Entity Type:Organization
Organization Name:DANIEL HUFFMAN BOLIN
Other - Org Name:GRACE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-761-3333
Mailing Address - Street 1:PO BOX 97555
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76307-7555
Mailing Address - Country:US
Mailing Address - Phone:940-761-3333
Mailing Address - Fax:940-766-6302
Practice Address - Street 1:1208 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5602
Practice Address - Country:US
Practice Address - Phone:940-761-3333
Practice Address - Fax:940-766-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1225038094Medicare PIN