Provider Demographics
NPI:1851552483
Name:SKYLINE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SKYLINE SURGERY CENTER, LLC
Other - Org Name:SKYLINE SURGERY CENTER INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKALEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-3877
Mailing Address - Street 1:285 VISTA DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-478-1704
Mailing Address - Fax:208-233-6970
Practice Address - Street 1:285 VISTA DR
Practice Address - Street 2:STE C
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-478-1704
Practice Address - Fax:208-233-6970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical