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Organization
GRENADA LAKE MEDICAL CENTER
Active
Organization
GRENADA LAKE MEDICAL CENTER
Active
Parent organization
GRENADA LAKE MEDICAL CENTER
Other names
Grenada Specialty Clinic - Terry Pummer
Organization subpart
Yes
Provider details
NPI number
Legal business name
GRENADA LAKE MEDICAL CENTER
Authorized official
MR. DAVID G. PUTT FACHE (CEO)
(662) 227-7000
Entity
Organization
Contact information
Practice address
965 AVENT DR STE 100A, GRENADA, MS 38901-5045
(662) 227-7444
(662) 227-7443
Mailing address
965 AVENT DR STE 100A, GRENADA, MS 38901-5045
(662) 227-7444
(662) 227-7443
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
21836
MS
Other
Enumeration date
02/15/2012
Last updated
03/18/2014
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