MEDICARE: SKY LAKES MEDICAL CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	14-0724-4	OR

General Provider Information

NPI Number	:	1811284268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKY LAKES MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	2865 DAGGETT AVE
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-1106
Country	:	US
Telephone Number	:	541-274-6221
Fax Number	:	541-274-6247

Provider Business Practice Location Address
First Line	:	2617 ALMOND ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-1116
Country	:	US
Telephone Number	:	541-274-6221
Fax Number	:	541-274-6247

Authorized Official
Title or Position	:	VP
Name	:	RICHARD E RICO
Credential	:
Telephone Number	:	541-274-6150

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	09/29/2011

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