| Organization Name: | GRENADA LAKE MEDICAL CENTER DME |
| NPI Number: | 1295700011 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CHARLES L DENTON (CEO) |
| Mailing Address: | 960 Avent Dr Grenada |
| State: | MS US |
| Postal Code: | 389015230 |
| Phone Number: | 6622277000 |
| Fax Number: | 6622277534 |
| NPI Enumeration Date: | 02/23/2006 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | 11245 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |