Provider Demographics
NPI:1699016337
Name:SHANNON MEDICAL CENTER
Entity type:Organization
Organization Name:SHANNON MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-657-8266
Mailing Address - Street 1:120 E HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-5904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2008 NINE RD
Practice Address - Street 2:
Practice Address - City:BRADY
Practice Address - State:TX
Practice Address - Zip Code:76825-7210
Practice Address - Country:US
Practice Address - Phone:325-597-2901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANNON MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAPPLIED FOR261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment