Healthcare Provider Details

I. General information

NPI: 1124437348
Provider Name (Legal Business Name): SKY LAKES MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 ALMOND ST
KLAMATH FALLS OR
97601-1116
US

IV. Provider business mailing address

2865 DAGGETT AVE
KLAMATH FALLS OR
97601-1106
US

V. Phone/Fax

Practice location:
  • Phone: 541-274-6221
  • Fax:
Mailing address:
  • Phone: 541-274-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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