Healthcare Provider Details

I. General information

NPI: 1215165642
Provider Name (Legal Business Name): GRENADA LAKE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 AVENT DR
GRENADA MS
38901-5230
US

IV. Provider business mailing address

960 AVENT DR
GRENADA MS
38901
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-7000
  • Fax: 662-227-7534
Mailing address:
  • Phone: 662-227-7000
  • Fax: 662-227-7534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number11-245
License Number StateMS

VIII. Authorized Official

Name: MR. CHARLES L DENTON
Title or Position: CEO
Credential:
Phone: 662-227-7000