1134302136 NPI number — GRENADA LAKE MEDICAL CENTER

Table of content: (NPI 1134302136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134302136 NPI number — GRENADA LAKE MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRENADA LAKE MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRENADA PRIMARY CARE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134302136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
965 AVENT DR STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38901-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-227-7575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
965 AVENT DR STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRENADA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38901-5045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-227-7575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2007

Additional Information

Authorized Official

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:
662-227-7000

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  11-245 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 282N00000X , with the licence number: 11-245 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com