MEDICARE: SKYWATER HEALTH

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	261QP2300X	Primary Care Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992734701	OTHER	CA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124589478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYWATER HEALTH

Provider Business Mailing Address
First Line	:	26516 CRENSHAW BLVD
Second Line	:
City	:	PALOS VERDES PENINSULA
State	:	CA
Zip	:	90274-3970
Country	:	US
Telephone Number	:	310-541-7911
Fax Number	:	310-541-4256

Provider Business Practice Location Address
First Line	:	26516 CRENSHAW BLVD
Second Line	:
City	:	PALOS VERDES PENINSULA
State	:	CA
Zip	:	90274-3970
Country	:	US
Telephone Number	:	310-541-7911
Fax Number	:	310-541-4256

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LORENA BARONI
Credential	:
Telephone Number	:	310-541-7911

Provider Enumeration Date	:	03/28/2019
Last Update Date	:	03/28/2019

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Directions to “SKYWATER HEALTH ” Practice Location

Language	Start Address	Practice Location

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