Healthcare Provider Details

I. General information

NPI: 1669578894
Provider Name (Legal Business Name): GRENADA LAKE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GRANDVIEW DR
GRENADA MS
38901-5066
US

IV. Provider business mailing address

1900 GRANDVIEW DR
GRENADA MS
38901-5066
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-5121
  • Fax: 662-226-7529
Mailing address:
  • Phone: 662-226-5121
  • Fax: 662-226-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SHELLEY SMITH
Title or Position: CLINICAL DIRECTOR
Credential: CFNP
Phone: 662-226-5121