Healthcare Provider Details

I. General information

NPI: 1588973788
Provider Name (Legal Business Name): MOUNTAIN LAKE MEDICAL GRP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6156 PONY EXPRESS TRL
POLLOCK PINES CA
95726-9649
US

IV. Provider business mailing address

6156 PONY EXPRESS TRL
POLLOCK PINES CA
95726-9649
US

V. Phone/Fax

Practice location:
  • Phone: 530-644-6044
  • Fax: 530-644-0125
Mailing address:
  • Phone: 530-644-6044
  • Fax: 530-644-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberG32582
License Number StateCA

VIII. Authorized Official

Name: WILLIAM MICHAEL CULVER
Title or Position: CEO/PHYSICIAN
Credential: M.D.
Phone: 530-644-6044