Provider Demographics
NPI:1386698207
Name:SKY LAKES MEDICAL CENTER INC
Entity type:Organization
Organization Name:SKY LAKES MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:RICO
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:541-274-6150
Mailing Address - Street 1:2865 DAGGETT AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1106
Mailing Address - Country:US
Mailing Address - Phone:541-274-6221
Mailing Address - Fax:541-274-6247
Practice Address - Street 1:2230 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6418
Practice Address - Country:US
Practice Address - Phone:541-274-8989
Practice Address - Fax:541-274-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138005000OtherBCBS REGENCE
OR207639Medicaid
OR138005000OtherBCBS REGENCE