Basic Information
| Provider Information | |||||||||
| NPI: | 1558391680 | ||||||||
| 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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| Mailing Information | |||||||||
| Address1: | 6330 SPRINT PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138142716 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9810 FM 1960 BYPASS RD W | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773383502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814465366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKAGGS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNATORY | ||||||||
| AuthorizedOfficialTelephone: | 9138142716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 11-3414024 | 01 | TX-COMMERCIAL NUMBER | OTHER | DMEH09152 | 05 | TX | MEDICAID | 001002269 | 05 | TX | MEDICAID | 113414024 | 01 | TX-COMMERCIAL NUMBER | OTHER | 114543 | 01 | TX-COMMERCIAL NUMBER | OTHER | 136494503 | 05 | TX | MEDICAID | 235397 | 01 | TX-COMMERCIAL NUMBER | OTHER | 0300339 | 01 | TX-COMMERCIAL NUMBER | OTHER | 564522 | 01 | TX-COMMERCIAL NUMBER | OTHER | 013100P | 01 | TX-COMMERCIAL NUMBER | OTHER | 1020575 | 01 | TX-COMMERCIAL NUMBER | OTHER | 1662975-01 | 05 | TX | MEDICAID | 457264 | 01 | TX-COMMERCIAL NUMBER | OTHER | 020100 | 01 | TX-COMMERCIAL NUMBER | OTHER | 1364945-03 | 05 | TX | MEDICAID | 2193368 | 01 | TX-COMMERCIAL NUMBER | OTHER | 300066126 | 01 | TX-COMMERCIAL NUMBER | OTHER |