Basic Information
| Provider Information | |||||||||
| NPI: | 1679181382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKY LAKES MEDICAL CENTER | ||||||||
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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: | 2821 DAGGETT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412748400 | ||||||||
| FaxNumber: | 5412748405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | PERLMAN | ||||||||
| AuthorizedOfficialFirstName: | HAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PFS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5412746651 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 500725155 | 05 | OR | MEDICAID | 152371 | 05 | OR | MEDICAID |