Provider Demographics
NPI:1194935569
Name:SHANNON SENIOR HEALTH CLINIC
Entity type:Organization
Organization Name:SHANNON SENIOR HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIETLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-949-9408
Mailing Address - Street 1:3016 VISTA DEL ARROYO DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6146
Mailing Address - Country:US
Mailing Address - Phone:325-949-9408
Mailing Address - Fax:
Practice Address - Street 1:3016 VISTA DEL ARROYO DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6146
Practice Address - Country:US
Practice Address - Phone:325-949-9408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4722207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID
=========OtherTAX ID