1285818849 NPI number — SHANNON CLINIC RP

Table of content: (NPI 1285818849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285818849 NPI number — SHANNON CLINIC RP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANNON CLINIC RP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285818849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90259
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76902-8059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-658-1511
Provider Business Mailing Address Fax Number:
325-659-0180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E BEAUREGARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76903-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-658-1511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VILLARREAL
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
Authorized Official Title or Position:
CAO
Authorized Official Telephone Number:
325-481-8248

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0057QQ . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".