Provider Demographics
NPI:1245572023
Name:SKY LAKES OUTPATIENT IMAGING
Entity Type:Organization
Organization Name:SKY LAKES OUTPATIENT IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:RICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-274-6150
Mailing Address - Street 1:2865 DAGGETT AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1106
Mailing Address - Country:US
Mailing Address - Phone:541-274-6221
Mailing Address - Fax:
Practice Address - Street 1:2900 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-7101
Practice Address - Country:US
Practice Address - Phone:541-274-6221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKY LAKES MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-20
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085B0100X
OR14-0724282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty