Provider Demographics
NPI:1144478512
Name:GRENADA ADULT HEALTHCARE CLINIC PC.
Entity type:Organization
Organization Name:GRENADA ADULT HEALTHCARE CLINIC PC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTICE
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:GONDWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-227-6450
Mailing Address - Street 1:965 J K AVENT DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5045
Mailing Address - Country:US
Mailing Address - Phone:662-227-6450
Mailing Address - Fax:662-227-6452
Practice Address - Street 1:965 J K AVENT DR
Practice Address - Street 2:SUITE 106
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-6450
Practice Address - Fax:662-227-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20373261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty