Basic Information
| Provider Information | |||||||||
| NPI: | 1659340370 | ||||||||
| 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: | 2865 DAGGETT AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412746221 | ||||||||
| FaxNumber: | 5412746247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 02/11/2010 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 282N00000X | 140724 | OR | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 01556 | 05 | OR | MEDICAID | 017881103 | 05 | OR | MEDICAID | 020406500A | 05 | OR | MEDICAID | 100457850A | 05 | OR | MEDICAID | 066167 | 05 | OR | MEDICAID | ZZR20101F | 05 | OR | MEDICAID | 152371 | 05 | OR | MEDICAID | 7126139 | 05 | OR | MEDICAID | 717315600 | 05 | OR | MEDICAID | 82508600 | 05 | OR | MEDICAID | HSP60101F | 05 | OR | MEDICAID | 011198 | 05 | OR | MEDICAID | 0033522 | 05 | OR | MEDICAID | 0413257 | 05 | OR | MEDICAID |