Healthcare Provider Details

I. General information

NPI: 1851552483
Provider Name (Legal Business Name): SKYLINE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 VISTA DR STE C
POCATELLO ID
83201
US

IV. Provider business mailing address

285 VISTA DRIVE SUITE C
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-1704
  • Fax: 208-233-6970
Mailing address:
  • Phone: 208-478-1704
  • Fax: 208-233-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN BUCKALEW
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-785-3877