Provider Demographics
NPI:1699005355
Name:GRENADA LAKE MEDICAL CENTER
Entity Type:Organization
Organization Name:GRENADA LAKE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
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 1:960 AVENT DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5230
Mailing Address - Country:US
Mailing Address - Phone:662-227-7000
Mailing Address - Fax:662-227-7534
Practice Address - Street 1:960 AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5230
Practice Address - Country:US
Practice Address - Phone:662-227-7000
Practice Address - Fax:662-227-7534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-245341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00050795Medicaid