Provider Demographics
NPI:1821289539
Name:SHANNON RURAL HEALTH CLINICS, INC
Entity Type:Organization
Organization Name:SHANNON RURAL HEALTH CLINICS, INC
Other - Org Name:SENIOR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVISIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-949-9408
Mailing Address - Street 1:PO BOX 1879
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-1879
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:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5439207Q00000X
TXH4593207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00027TMedicare PIN