| Organization Name: | MOUNTAIN LAKE MEDICAL GRP PC |
| NPI Number: | 1588973788 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | WILLIAM MICHAEL CULVER (CEO/PHYSICIAN) |
| Mailing Address: | 6156 Pony Express Trl Pollock Pines |
| State: | CA US |
| Postal Code: | 957269649 |
| Phone Number: | 5306446044 |
| Fax Number: | 5306440125 |
| NPI Enumeration Date: | 10/05/2010 |
| NPI Last Update Date: | 02/16/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | G32582 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |