Provider Demographics
NPI:1639250046
Name:MOUNTAIN LAKES MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:MOUNTAIN LAKES MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAPHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RCP
Authorized Official - Phone:909-585-1339
Mailing Address - Street 1:PO BOX 1679
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92314-9050
Mailing Address - Country:US
Mailing Address - Phone:909-585-1339
Mailing Address - Fax:909-585-3646
Practice Address - Street 1:226 E. FAIRWAY BLVD
Practice Address - Street 2:
Practice Address - City:BIG BEAR CITY
Practice Address - State:CA
Practice Address - Zip Code:92314-9050
Practice Address - Country:US
Practice Address - Phone:909-585-1339
Practice Address - Fax:909-585-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102727332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD08601548OtherSUBMITTER ID
CADME01937FMedicaid
CA4129290001Medicare NSC