| Mountain Lake Medical Grp Pc | |
|
6156 Pony Express Trl Pollock Pines CA 95726-9649 | |
| (530) 644-6044 | |
| (530) 644-0125 |
| Full Name | Mountain Lake Medical Grp Pc |
|---|---|
| Speciality | Clinic/center - Primary Care |
| Location | 6156 Pony Express Trl, Pollock Pines, California |
| Authorized Official Name and Position | William Michael Culver (CEO/PHYSICIAN) |
| Authorized Official Contact | 5306446044 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Mountain Lake Medical Grp Pc 6156 Pony Express Trl Pollock Pines CA 95726-9649 Ph: (530) 644-6044 | Mountain Lake Medical Grp Pc 6156 Pony Express Trl Pollock Pines CA 95726-9649 Ph: (530) 644-6044 |
| NPI Number | 1588973788 |
|---|---|
| Provider Enumeration Date | 10/05/2010 |
| Last Update Date | 02/16/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1588973788 | NPI | - | NPPES |
| 4774218 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | G32582 (California) | Primary |