Organization
GRENADA LAKE MEDICAL CENTER
Active
Other names
Grenada Specialty Clinic (GSC)
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 38901-5230
(662) 227-7000
(662) 227-7534
Mailing address
960 J K AVENT DR, GRENADA, MS 38901-5230
(662) 227-7000
(662) 227-7534
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04557869
—
MS
01
—
C03391
MEDICARE PROVIDER #
MS
Enumeration date
11/02/2006
Last updated
03/04/2011
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