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General NPI Number Information
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NPI Number | 1710417761
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Entity Type | Organization
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Legal Business Name | BRAZOS VALLEY ER, LLC
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Dates
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Enumeration Date | 06/13/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2411 BOONVILLE RD
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City | BRYAN
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State | TX
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Zip | 77808-2231
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Country | US
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Telephone | 979-775-0911
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Fax | 512-825-4625
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Provider Business Mailing Address
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Address Line | PO BOX 61041
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City | CORPUS CHRISTI
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State | TX
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Zip | 78466-1041
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Country | US
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Telephone | 361-884-2904
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Fax |
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Authorized Official
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Title or Position | LLC MEMBER/MANAGER
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Name | MR. JARED SHAHAN
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Credential | MD
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Telephone | 361-991-0912
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0002X
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Taxonomy Name | Emergency Care Clinic/Center
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License Number |
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License Number State |
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