| Details | Last Recertification Date | Update | Recertification | 1/29/2024 3:53:44 PM | 2/14/2025 4:55:26 PM | 2/14/2025 4:55 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Elder, Julie
Interim CEO
GraceMed Health Clinic
3168662000-2066 | Elder, Julie
CEO
GraceMed Health Clinic
3168662000-2066 | 2/11/2025 10:37 AM |
| Contacts | Authorizing Official | Update | Group Change Request | Lee, Venus
Chief Executive Officer
GraceMed Health Clinic, Inc.
3168662064 | Elder, Julie
Interim CEO
GraceMed Health Clinic
3168662000-2066 | 12/23/2024 8:54 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2023 2:28:07 PM | 1/29/2024 3:53:44 PM | 1/29/2024 3:53 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2022 12:00:19 PM | 1/30/2023 2:28:07 PM | 1/30/2023 2:28 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2021 1:35:19 PM | 1/31/2022 12:00:19 PM | 1/31/2022 12:00 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2020 3:46:48 PM | 2/3/2021 1:35:19 PM | 2/3/2021 1:35 PM |
| Contacts | Authorizing Official | Update | Change Request | SANFORD, DAVID C.
CEO
GraceMed Health Clinic, Inc.
3164942001 | Lee, Venus
Chief Executive Officer
GraceMed Health Clinic, Inc.
3168662064 | 11/16/2020 12:04 PM |
| Contacts | Primary Contact | Update | Change Request | Lee, Venus
Chief Executive Officer
GraceMed Health Clinic, Inc.
3168662064 | Wuthnow, David
CFO
GraceMed Health Clinic
3168662049 | 11/16/2020 12:04 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Lee, Venus
Assocaite Executive Officer
GraceMed Health Clinic, Inc.
3168662064 | Lee, Venus
Chief Executive Officer
GraceMed Health Clinic, Inc.
3168662064 | 6/5/2020 1:34 PM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2019 10:48:51 AM | 1/30/2020 3:46:48 PM | 1/30/2020 3:46 PM |
| Details | Last Recertification Date | Update | Recertification | 2/10/2018 1:25:19 PM | 2/4/2019 10:48:51 AM | 2/4/2019 10:48 AM |
| Contacts | Primary Contact | Update | Recertification | SANFORD, DAVID C.
CEO
GraceMed Health Clinic, Inc.
3164942001 | Lee, Venus
Assocaite Executive Officer
GraceMed Health Clinic, Inc.
3168662064 | 2/10/2018 1:25 PM |
| Details | Last Recertification Date | Update | Recertification | 1/25/2017 12:00:00 AM | 2/10/2018 1:25:19 PM | 2/10/2018 1:25 PM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/10/2018 1:25 PM |
| Contacts | Authorizing Official | Update | | SANFORD, DAVID C.
CEO
3164942001 | SANFORD, DAVID C.
CEO
GraceMed Health Clinic, Inc.
3164942001 | 2/10/2018 1:03 PM |
| Contacts | Primary Contact | Update | | SANFORD, DAVID C.
CEO
3164942001 | SANFORD, DAVID C.
CEO
GraceMed Health Clinic, Inc.
3164942001 | 2/10/2018 1:03 PM |
| Contacts | Signed By | Update | | SANFORD, DAVID C.
CEO
3164942001 | SANFORD, DAVID C.
CEO
GraceMed Health Clinic, Inc.
3164942001 | 2/10/2018 1:03 PM |
| Contacts | Authorizing Official | Insert | | | SANFORD, DAVID C.
CEO
3164942001 | 8/3/2017 4:06 PM |
| Contacts | Primary Contact | Insert | | | SANFORD, DAVID C.
CEO
3164942001 | 8/3/2017 4:06 PM |
| Contacts | Signed By | Insert | | | SANFORD, DAVID C.
CEO
3164942001 | 8/3/2017 4:06 PM |
| Addresses | Main Address | Insert | | |
755 W. Lincoln St.
Wichita, KS 67213 | 1/25/2017 10:20 AM |
| Details | Last Recertification Date | Update | | | 1/25/2017 12:00:00 AM | 1/25/2017 10:20 AM |
| Addresses | Billing Address | Insert | | | GraceMed Health Clinic, Inc.
1122 N. Topeka St.
Wichita, KS 67214 | 1/6/2016 1:41 PM |
| Dates | Participating Approval Date | Update | | | 1/6/2016 12:00:00 AM | 1/6/2016 1:41 PM |
| Details | State | Update | | Pending | Active | 1/6/2016 1:41 PM |
| Dates | Start Date | Update | | | 4/1/2016 12:00:00 AM | 1/6/2016 1:41 PM |
| Details | 340B ID | Update | | ONLINE_REG_56455 | CHC08772-09 | 1/5/2016 12:07 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_56455 | 1/4/2016 1:02 PM |
| Details | Last Recertification Date | Insert | | | | 1/4/2016 1:02 PM |
| Details | Grant Number | Insert | | | H80CS08772 | 1/4/2016 1:02 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/4/2016 1:02 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 1/4/2016 1:02 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/4/2016 1:02 PM |
| Details | Medicare Provider Number | Insert | | | | 1/4/2016 1:02 PM |
| Details | Entity Name | Insert | | | GRACEMED HEALTH CLINIC, INC. | 1/4/2016 1:02 PM |
| Details | Program Code | Insert | | | CH | 1/4/2016 1:02 PM |
| Details | Entity Subname | Insert | | | GraceMed Meyer Family Clinic | 1/4/2016 1:02 PM |
| Dates | Participating Approval Date | Insert | | | | 1/4/2016 1:02 PM |
| Details | State | Insert | | | Pending | 1/4/2016 1:02 PM |
| Dates | Registration Date | Insert | | | 1/4/2016 12:00:00 AM | 1/4/2016 1:02 PM |
| Dates | Signed By Date | Insert | | | 1/4/2016 12:00:00 AM | 1/4/2016 1:02 PM |
| Dates | Start Date | Insert | | | | 1/4/2016 1:02 PM |
| Terminations | Termination Comments | Insert | | | | 1/4/2016 1:02 PM |
| Terminations | Termination Date | Insert | | | | 1/4/2016 1:02 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/4/2016 1:02 PM |
| Terminations | Termination Reason | Insert | | | | 1/4/2016 1:02 PM |