Basic Information
| Provider Information | |||||||||
| NPI: | 1467961250 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HOSPITAL DISTRICT NO 2, KLICKITAT COUNTY, WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SKYLINE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986720099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094931101 | ||||||||
| FaxNumber: | 5094934607 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 NE SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096372810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2017 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | KIMMES | ||||||||
| AuthorizedOfficialFirstName: | ROBB | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5096372919 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SKYLINE HOSPITAL | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.