Healthcare Provider Details

I. General information

NPI: 1245572023
Provider Name (Legal Business Name): SKY LAKES OUTPATIENT IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DAGGETT AVE
KLAMATH FALLS OR
97601-7101
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 TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number14-0724
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

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