NPIMap

Organization Active NPI

Grenada Lake Medical Center

Doing business as Grenada Primary Care Clinic

  • Rural Health Clinic/Center
  • Grenada, MS
National Provider Identifier
1154506277
Registry record updated Jan 8, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
11-245 Issued in MS
Legal business name
GRENADA LAKE MEDICAL CENTER
Doing business as
Grenada Primary Care Clinic
Practice address
965 Avent Dr Ste 105
Grenada, MS 38901-5045
Phone
(662) 227-7575
NPI assigned
Jan 8, 2008
Last updated
Jan 8, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 8, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Charles L Denton
Title
Ceo
Phone
(662) 227-7005

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 11-245 MS Primary

Addresses

Primary practice location

965 Avent Dr Ste 105
Grenada, MS 38901-5045

Mailing address

965 Avent Dr Ste 105
Grenada, MS 38901-5045
Phone (662) 227-7575

Other names 1

  • Grenada Primary Care Clinic Doing business as

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

965 Avent Dr
Ste 102
Grenada, MS 38901
Phone (662) 227-7000

965 Avent Dr
Ste 105
Grenada, MS 38901
Phone (662) 227-0998

965 Avent Dr
Ste 107
Grenada, MS 38901
Phone (662) 227-7000

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1199750400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1199750400000",
    "number": "1154506277",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "965 AVENT DR STE 105",
            "city": "GRENADA",
            "state": "MS",
            "postal_code": "389015045",
            "telephone_number": "662-227-7575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "965 AVENT DR STE 105",
            "city": "GRENADA",
            "state": "MS",
            "postal_code": "389015045",
            "telephone_number": "662-227-7575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRENADA LAKE MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-08",
        "last_updated": "2008-01-08",
        "status": "A",
        "authorized_official_last_name": "DENTON",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "662-227-7005",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": "11-245",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Grenada Primary Care Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grenada, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.