Healthcare Provider Details

I. General information

NPI: 1912058231
Provider Name (Legal Business Name): GRENADA FAMILY MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418B N APPLEGATE ST
WINONA MS
38967-1827
US

IV. Provider business mailing address

1300 SUNSET DR STE F
GRENADA MS
38901-4083
US

V. Phone/Fax

Practice location:
  • Phone: 662-283-4433
  • Fax: 662-283-4434
Mailing address:
  • Phone: 662-283-4433
  • Fax: 662-283-4434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RALPH C ARMSTRONG JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 662-226-5747