Basic Information
| Provider Information | |||||||||
| NPI: | 1295761997 | ||||||||
| 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: | 4401 MASTHEAD ST NE STE 105 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053453754 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKAGGS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9138142716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0000N1425 | 05 | NM | MEDICAID | 60-03419 | 01 | NM-COMMERCIAL NUMBER | OTHER | 000A8575 | 05 | NM | MEDICAID | 54826 | 01 | NM-COMMERCIAL NUMBER | OTHER | 565800 | 01 | NM-COMMERCIAL NUMBER | OTHER | ANC015 | 01 | NM-COMMERCIAL NUMBER | OTHER | 28689 | 01 | NM-COMMERCIAL NUMBER | OTHER | 300066102 | 01 | NM-COMMERCIAL NUMBER | OTHER | 000F1512 | 05 | NM | MEDICAID | 112207 | 01 | NM-COMMERCIAL NUMBER | OTHER | 327070 | 01 | NM-COMMERCIAL NUMBER | OTHER | 689703 | 01 | NM-COMMERCIAL NUMBER | OTHER | 013100P | 01 | NM-COMMERCIAL NUMBER | OTHER | 827390 | 01 | NM-COMMERCIAL NUMBER | OTHER | 8413-90 | 01 | NM-COMMERCIAL NUMBER | OTHER | 146544 | 01 | NM-COMMERCIAL NUMBER | OTHER | N1425 | 05 | NM | MEDICAID |