Healthcare Provider Details

I. General information

NPI: 1710417761
Provider Name (Legal Business Name): BRAZOS VALLEY ER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 BOONVILLE RD
BRYAN TX
77808-2231
US

IV. Provider business mailing address

PO BOX 61041
CORPUS CHRISTI TX
78466-1041
US

V. Phone/Fax

Practice location:
  • Phone: 979-775-0911
  • Fax: 512-825-4625
Mailing address:
  • Phone: 361-884-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JARED SHAHAN
Title or Position: LLC MEMBER/MANAGER
Credential: MD
Phone: 361-991-0912