Provider Demographics
NPI:1649446691
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:541-274-6733
Mailing Address - Fax:541-274-6247
Practice Address - Street 1:2821 DAGGETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1130
Practice Address - Country:US
Practice Address - Phone:541-274-6733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKY LAKES MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-30
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR066167Medicaid
OR500740745Medicaid
OR002500XGGMedicaid