Basic Information
| Provider Information | |||||||||
| NPI: | 1386698207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKY LAKES MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 DAGGETT AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412746221 | ||||||||
| FaxNumber: | 5412746247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 N ELDORADO AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976016418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412748989 | ||||||||
| FaxNumber: | 5412744334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 05/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | RICO | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 5412746150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 138005000 | 01 | OR | BCBS REGENCE | OTHER | 207639 | 05 | OR | MEDICAID |