# GRENADA LAKE MEDICAL CENTER

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** GRENADA LAKE MEDICAL CENTER
- **Other names:** Grenada Specialty Clinic - Terry Pummer
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1053684548
- **Legal business name:** GRENADA LAKE MEDICAL CENTER
- **Authorized official:** MR. DAVID G. PUTT FACHE (CEO)
- **Authorized official phone:** (662) 227-7000

## Contact information

- **Practice address:** 965 AVENT DR STE 100A, GRENADA, MS 38901-5045
- **Practice address phone:** (662) 227-7444
- **Practice address fax:** (662) 227-7443
- **Mailing address:** 965 AVENT DR STE 100A, GRENADA, MS 38901-5045
- **Mailing address phone:** (662) 227-7444
- **Mailing address fax:** (662) 227-7443

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 21836 | MS | Yes |

## Other

- **Enumeration date:** 02/15/2012
- **Last updated:** 03/18/2014