Organization
SHANNON CLINIC RP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICARDO VILLARREAL (CAO)
(325) 481-8248
Entity
Organization
Contact information
Practice address
120 E BEAUREGARD AVE, SAN ANGELO, TX 76903-5919
(325) 658-1511
Mailing address
PO BOX 90259, SAN ANGELO, TX 76902-8059
(325) 658-1511
(325) 659-0180
Taxonomy
Speciality
Code
Description
License number
State
207ZP0101X
Anatomic Pathology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0057QQ
BCBS GROUP
TX
Enumeration date
12/19/2007
Last updated
01/21/2020
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