Provider Demographics
NPI:1619055563
Name:GRACIA MEDICAL, LLP
Entity Type:Organization
Organization Name:GRACIA MEDICAL, LLP
Other - Org Name:BOHMAN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KEEFAUVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-275-2381
Mailing Address - Street 1:2500 N ESPLANADE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-4727
Mailing Address - Country:US
Mailing Address - Phone:361-275-2381
Mailing Address - Fax:361-275-2431
Practice Address - Street 1:2500 N ESPLANADE ST STE 101
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-4727
Practice Address - Country:US
Practice Address - Phone:361-275-2381
Practice Address - Fax:361-275-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170895003Medicaid
TX0032LZOtherBCBS
TX170895008Medicaid
TX170895009Medicaid
TX0032LZOtherBCBS
TX453971Medicare Oscar/Certification
TX5380400001Medicare NSC