Provider Demographics
NPI:1568417103
Name:SKY LAKES MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SKY LAKES MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:RICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-274-6150
Mailing Address - Street 1:2605 CROSBY AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-5726
Mailing Address - Country:US
Mailing Address - Phone:541-274-6293
Mailing Address - Fax:541-274-6294
Practice Address - Street 1:2605 CROSBY AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-5726
Practice Address - Country:US
Practice Address - Phone:541-274-6293
Practice Address - Fax:541-274-6294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13 140724251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXHHA10140Medicaid
OR044883Medicaid
OR138005000OtherBCBS REGENCE
OR044883Medicaid