Provider Demographics
NPI:1659340370
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 1:2865 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:541-274-6247
Practice Address - Street 1:2865 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1106
Practice Address - Country:US
Practice Address - Phone:541-274-6221
Practice Address - Fax:541-274-6247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
OR140724282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01556Medicaid
OR017881103Medicaid
OR020406500AMedicaid
OR100457850AMedicaid
OR066167Medicaid
ORZZR20101FMedicaid
OR152371Medicaid
OR7126139Medicaid
OR717315600Medicaid
OR82508600Medicaid
ORHSP60101FMedicaid
OR011198Medicaid
OR0033522Medicaid
OR0413257Medicaid
ORHSP60101FMedicaid
OR152371Medicaid
OR380050Medicare Oscar/Certification
OR011198Medicaid
ORR0000ZGBGHMedicare PIN