Organization
GRENADA LAKE MEDICAL CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHARLES L DENTON (CEO)
(662) 227-7000
Entity
Organization
Contact information
Practice address
960 J K AVENT DR, GRENADA, MS 38901
(662) 227-7000
(662) 227-6538
Mailing address
960 J K AVENT DR, GRENADA, MS 38901
(662) 227-7000
(662) 227-6538
Taxonomy
Speciality
Code
Description
License number
State
282N00000X
General Acute Care Hospital
Primary
11-245
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000019026A
BX CRNA #
MS
05
—
09013480
—
MS
Enumeration date
12/20/2006
Last updated
08/10/2012
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