Provider Demographics
NPI:1073051967
Name:SKY RIDGE MEDICAL
Entity Type:Organization
Organization Name:SKY RIDGE MEDICAL
Other - Org Name:SKY RIDGE MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:720-515-8002
Mailing Address - Street 1:5950 S WILLOW DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-5144
Mailing Address - Country:US
Mailing Address - Phone:720-515-8002
Mailing Address - Fax:303-741-2676
Practice Address - Street 1:5950 S WILLOW DR STE 200
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-5144
Practice Address - Country:US
Practice Address - Phone:720-515-8002
Practice Address - Fax:303-741-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0006922332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies