Provider Demographics
NPI:1588973788
Name:MOUNTAIN LAKE MEDICAL GRP PC
Entity type:Organization
Organization Name:MOUNTAIN LAKE MEDICAL GRP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-644-6044
Mailing Address - Street 1:6156 PONY EXPRESS TRL
Mailing Address - Street 2:
Mailing Address - City:POLLOCK PINES
Mailing Address - State:CA
Mailing Address - Zip Code:95726-9649
Mailing Address - Country:US
Mailing Address - Phone:530-644-6044
Mailing Address - Fax:530-644-0125
Practice Address - Street 1:6156 PONY EXPRESS TRL
Practice Address - Street 2:
Practice Address - City:POLLOCK PINES
Practice Address - State:CA
Practice Address - Zip Code:95726-9649
Practice Address - Country:US
Practice Address - Phone:530-644-6044
Practice Address - Fax:530-644-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32582261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4774218Medicaid
CA4774218Medicaid
CAA45203Medicare UPIN