Healthcare Provider Details

I. General information

NPI: 1003654625
Provider Name (Legal Business Name): SKY LAKES MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 DAGGETT AVE STE B
KLAMATH FALLS OR
97601-1106
US

IV. Provider business mailing address

2865 DAGGETT AVE STE B
KLAMATH FALLS OR
97601-1106
US

V. Phone/Fax

Practice location:
  • Phone: 541-274-3760
  • Fax: 541-274-3765
Mailing address:
  • Phone: 541-274-3760
  • Fax: 541-274-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RICHARD E RICO
Title or Position: VP / CFO
Credential:
Phone: 541-274-6150