NPIMap

Organization Active NPI

Shannon Clinic

  • Rural Health Clinic/Center
  • Ozona, TX
National Provider Identifier
1245230465
Registry record updated Feb 27, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SHANNON CLINIC
Practice address
102 North Avenue H
Ozona, TX 76943-0907
Phone
(325) 392-3788
Fax
(325) 392-5445
NPI assigned
Jul 29, 2005
Last updated
Feb 27, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 27, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ricardo Villarreal
Title
Cao
Phone
(325) 481-8248

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

102 North Avenue H
Ozona, TX 76943-0907

Mailing address

PO Box 22000
San Angelo, TX 76902-7200
Phone (325) 658-1511

Other identifiers 1

IdentifierTypeStateIssuer
149090601MedicaidTX

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031222000702 TX Part B Supplier - Clinic/Group Practice 0840103727 Receives reassigned benefits from 677 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: San Angelo, TX; Vidor, TX; Big Spring, TX; Del Rio, TX; Dripping Springs, TX; Ozona, TX; Houston, TX
O20091124000208 TX Part A Provider - Rural Health Clinic 0840103727 Practice locations: Ozona, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1245230465. Details of each certification follow.

Rural health clinic certification: CCN 673841

Legal name
SHANNON CLINIC
Doing business as
FAMILY HEALTH CENTER OF OZONA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 25, 2002
Last certification
Sep 7, 2016
Ownership / control type
2B
Most recent change of ownership
Jan 1, 2010 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 1995 in TX
Enrollment address
102 Avenue H
Family Health Center of Ozona
Ozona, TX 76943-0907

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Shannon Clinic7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Locations

800 N Main Ave
Big Lake, TX 76932
Phone (325) 481-2183

Ownership & related parties

All disclosed owners & managing parties 29

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Ricardo Villarreal Individual Corporate OfficerChief Aministration Officer Feb 1, 2018
Laura Adams Individual Corporate Director Oct 1, 2007
Leonard Mertz Individual Corporate Director May 4, 1999
Jonathan S Gipson Individual Corporate Director Oct 1, 2007
John C Harvey Individual Corporate Director Oct 1, 2007
Joanne Rice Individual Corporate Director Oct 1, 2007
Harvey D Russwurm Individual Corporate Director Oct 1, 2007
Oran Berry Individual Corporate Director Jan 8, 2004
Emmette Flynn Individual Corporate Director Oct 1, 2007
Joseph Henderson Individual Corporate Director Apr 15, 1997
Shannon Medical Center Organization, San Angelo, TX Non-profit Operational/Managerial Control Jan 1, 2010
Mary T Seger Individual Corporate Director Oct 1, 2007
Joe a Mims Individual Corporate Director Oct 1, 2007
Luis E Duarte Individual Corporate Director Oct 1, 2007
Michael Boyd Individual Corporate Director Jan 2, 2005
Michelle G Snuggs Individual Corporate Director Oct 1, 2007
Viki a Forlano Individual Corporate Director Oct 1, 2007
Michael Oliphant Individual Corporate Director Aug 6, 2007
Cornelius W Chinn Individual Corporate Director Oct 1, 2007
Pamela Talley Individual Corporate Director Oct 1, 2007
James C Cole Individual Corporate Director Oct 1, 2007
William F Whitehead Individual Corporate Director Oct 1, 2007
Michael a Wagnon Individual Corporate Director Oct 1, 2007
Robert D Schultz Individual W-2 Managing Employee Jan 1, 2010
James E. Melott Individual Corporate Director Oct 1, 2007
Irvin E Zeitler Individual Corporate Director Oct 1, 2005
Kelly Plymell Individual Corporate Director Dec 1, 2006
Stephen P Sawyer Individual Corporate Director Oct 1, 2007
John Cecil Individual Corporate Director Oct 1, 2007

Owners & managing parties with NPI records 16

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 16

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1122595200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582761600000",
    "number": "1245230465",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 22000",
            "city": "SAN ANGELO",
            "state": "TX",
            "postal_code": "769027200",
            "telephone_number": "325-658-1511",
            "fax_number": "325-481-2166"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 NORTH AVENUE H",
            "city": "OZONA",
            "state": "TX",
            "postal_code": "769430907",
            "telephone_number": "325-392-3788",
            "fax_number": "325-392-5445"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHANNON CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-29",
        "last_updated": "2020-02-27",
        "certification_date": "2020-02-27",
        "status": "A",
        "authorized_official_last_name": "VILLARREAL",
        "authorized_official_first_name": "RICARDO",
        "authorized_official_title_or_position": "CAO",
        "authorized_official_telephone_number": "325-481-8248"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "149090601",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ozona, TX

Sources for this page

Verify at the official NPI Registry.