Provider Demographics
NPI:1922187095
Name:GRENADA LAKE MEDICAL CENTER
Entity Type:Organization
Organization Name:GRENADA LAKE MEDICAL CENTER
Other - Org Name:GRENADA SPECIALTY CLINIC (GSC)
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 1:960 J K 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 J K 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:2006-11-02
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03391OtherMEDICARE PROVIDER #
MS04557869Medicaid