Organization
SHANNON CLINIC
Active
Other names
SHANNON CLINIC ORTHOTICS
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) 653-9235
(325) 653-9284
Mailing address
PO BOX 22000, SAN ANGELO, TX 76902-7200
(325) 658-1511
(325) 481-2165
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
1210
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1033840001
—
TX
Enumeration date
07/10/2010
Last updated
01/21/2020
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