# GRENADA LAKE MEDICAL CENTER

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Grenada Primary Care Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1134302136
- **Authorized official:** MR. CHARLES L DENTON (CEO)
- **Authorized official phone:** (662) 227-7000

## Contact information

- **Practice address:** 965 AVENT DR STE 105, GRENADA, MS 38901-5045
- **Practice address phone:** (662) 227-7575
- **Mailing address:** 965 AVENT DR STE 105, GRENADA, MS 38901-5045
- **Mailing address phone:** (662) 227-7575

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | 11-245 | MS | Yes |
| 282N00000X | General Acute Care Hospital | 11-245 | MS | — |

## Other

- **Enumeration date:** 12/12/2007
- **Last updated:** 12/17/2007