Basic Information
| Provider Information | |||||||||
| NPI: | 1194757468 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENTIVA CERTIFIED HEALTHCARE CORP. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTERWELL HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6330 SPRINT PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138142716 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1970 OAKCREST AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551132624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516366330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKAGGS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNATORY | ||||||||
| AuthorizedOfficialTelephone: | 9138142716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 071755000 | 05 | MN | MEDICAID | 5900031 | 01 | MN-COMMERCIAL NUMBER | OTHER | 113414024D | 01 | MN-COMMERCIAL NUMBER | OTHER | 41525000 | 05 | WI | MEDICAID | 4614OL | 05 | MN | MEDICAID | 013100P | 01 | MN-COMMERCIAL NUMBER | OTHER | 565732 | 01 | MN-COMMERCIAL NUMBER | OTHER | 071755000 | 01 | MN-COMMERCIAL NUMBER | OTHER | 106825087 | 01 | MN-COMMERCIAL NUMBER | OTHER | 247145 | 01 | MN-COMMERCIAL NUMBER | OTHER | 41532800 | 01 | MN-COMMERCIAL NUMBER | OTHER | 41525000 | 05 | MN | MEDICAID | 5900033 | 01 | MN-COMMERCIAL NUMBER | OTHER | 5900033 | 05 | MN | MEDICAID | 169027 | 05 | MN | MEDICAID | 4614OL | 01 | MN-COMMERCIAL NUMBER | OTHER | 109673 | 01 | MN-COMMERCIAL NUMBER | OTHER | 169027 | 01 | MN-COMMERCIAL NUMBER | OTHER |