SHANE GILLIAM, M.D., P.A.
Ambulatory Health at Graham St, Stephenville, TX

License number
Texas L7278
Category
Ambulatory Health
Type
Primary Care
Owner
Name: DR. LESLIE SHANE GILLIAM M.D.
Title: PHYSICIAN/OWNER
Phone: (254) 965-8760
Address
Address
630 N Graham St, Stephenville, TX 76401
National Provider ID: 1891003802
LicenseFiles verified this license of Nov 7, 2017 at the National Plan and Provider Enumeration System.

Organization information

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SHANE GILLIAM, M.D., PA

Stephenville, TX

Registration:
May 17, 2007
Addresses:
205 E Frey St STE 201, Stephenville, TX 76401 (Mailing)
110 Hudson Ct, Stephenville, TX 76401
State ID:
0800816894
Business type:
Professional Association
President , Treasurer , Secretary , Director , Member , Vice-Presidents:
Leslie Gilliam (Director, Member, President, Secretary),Shane Gilliam President , Treasurer , Secretary , Director , Member , Vice-President, inactive
Agent:
Gilliam Shane,205 E Frey STE 201, Stephenville, TX 76401 (Physical)
TIN:
32035019812

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