Healthcare Provider Details

I. General information

NPI: 1053386870
Provider Name (Legal Business Name): GRENADA LAKE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 12/12/2007
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
38901-5230
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 Code314000000X
TaxonomySkilled Nursing Facility
License Number11245
License Number StateMS

VIII. Authorized Official

Name: CHARLES L DENTON
Title or Position: CEO
Credential:
Phone: 662-227-7005