Organization
SHANNON CLINIC
Active
Organization
SHANNON CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICARDO VILLARREAL (CAO)
(325) 481-8248
Entity
Organization
Contact information
Practice address
110 E TWOHIG AVE, SAN ANGELO, TX 76903-5916
(325) 658-1511
(325) 481-2166
Mailing address
PO BOX 22000, SAN ANGELO, TX 76902-7200
(325) 658-1511
(325) 481-2166
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
1210
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CPED4075
CERTIFICATION
TX
Enumeration date
05/13/2014
Last updated
01/21/2020
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