| Organization Name: | GRENADA LAKE MEDICAL CENTER |
| NPI Number: | 1154506277 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CHARLES L DENTON (CEO) |
| Mailing Address: | 965 Avent Dr Ste 105 Grenada |
| State: | MS US |
| Postal Code: | 389015045 |
| Phone Number: | 6622277575 |
| Fax Number: | |
| NPI Enumeration Date: | 01/08/2008 |
| NPI Last Update Date: | 01/08/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | 11-245 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |