MEDICARE: MOUNTAIN LAKES MEDICAL SUPPLY INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	102727	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D08601548	OTHER	CA	SUBMITTER ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639250046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN LAKES MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	PO BOX 1679
Second Line	:
City	:	BIG BEAR CITY
State	:	CA
Zip	:	92314-9050
Country	:	US
Telephone Number	:	909-585-1339
Fax Number	:	909-585-3646

Provider Business Practice Location Address
First Line	:	226 E. FAIRWAY BLVD
Second Line	:
City	:	BIG BEAR CITY
State	:	CA
Zip	:	92314-9050
Country	:	US
Telephone Number	:	909-585-1339
Fax Number	:	909-585-3646

Authorized Official
Title or Position	:	OWNER OPERATOR
Name	:	MARC K LAPHAM
Credential	:	RCP
Telephone Number	:	909-585-1339

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	07/18/2008

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