Provider Demographics
NPI:1134302136
Name:GRENADA LAKE MEDICAL CENTER
Entity Type:Organization
Organization Name:GRENADA LAKE MEDICAL CENTER
Other - Org Name:GRENADA PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:DENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-227-7000
Mailing Address - Street 1:965 AVENT DR STE 105
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5045
Mailing Address - Country:US
Mailing Address - Phone:662-227-7575
Mailing Address - Fax:
Practice Address - Street 1:965 AVENT DR STE 105
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-245261Q00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No282N00000XHospitalsGeneral Acute Care Hospital