Provider Demographics
NPI:1619055571
Name:GRACIA MEDICAL, LLP
Entity Type:Organization
Organization Name:GRACIA MEDICAL, LLP
Other - Org Name:YORKTOWN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
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 1:508 N RIEDEL ST
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78164-1810
Mailing Address - Country:US
Mailing Address - Phone:361-564-3383
Mailing Address - Fax:361-564-4224
Practice Address - Street 1:508 N RIEDEL ST
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:TX
Practice Address - Zip Code:78164-1810
Practice Address - Country:US
Practice Address - Phone:361-564-3383
Practice Address - Fax:361-564-4224
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 - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170895010Medicaid
TX170895011Medicaid
TX170895003Medicaid
TX0032LZOtherBCBS
TX673874Medicare Oscar/Certification
TX5380400005Medicare NSC
TX00634XMedicare PIN