Provider Demographics
NPI:1588646392
Name:SHANNON JOINT VENTURES, INC
Entity Type:Organization
Organization Name:SHANNON JOINT VENTURES, INC
Other - Org Name:SHANNON DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBREATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-658-1511
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-659-7360
Mailing Address - Fax:
Practice Address - Street 1:2018 PULLIAM ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76905-5148
Practice Address - Country:US
Practice Address - Phone:325-659-7360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANNON HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-17
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1646207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148371102Medicaid
TX452839Medicare PIN