Provider Demographics
NPI:1689386807
Name:SKY VALLEY PSYCHEDELIC MEDICAL
Entity Type:Organization
Organization Name:SKY VALLEY PSYCHEDELIC MEDICAL
Other - Org Name:SKY VALLEY PSYCHEDELIC MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PALMER
Authorized Official - Last Name:LOVEJOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-949-7555
Mailing Address - Street 1:40016 145TH PL SE
Mailing Address - Street 2:
Mailing Address - City:GOLD BAR
Mailing Address - State:WA
Mailing Address - Zip Code:98251-9471
Mailing Address - Country:US
Mailing Address - Phone:707-239-6190
Mailing Address - Fax:707-239-6190
Practice Address - Street 1:101 E MAIN ST STE 209
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-949-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center