Basic Information
| Provider Information | |||||||||
| NPI: | 1619909884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENTIVA CERTIFIED HEALTHCARE CORP. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| 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: | 2120 S WALDRON RD BLDG C | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794520424 | ||||||||
| FaxNumber: | 4794520960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
| 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: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 145450752 | 05 | AR | MEDICAID | 047038 | 01 | AR-COMMERCIAL NUMBER | OTHER | 0564382 | 01 | AR-COMMERCIAL NUMBER | OTHER | 138833742 | 05 | AR | MEDICAID | 145487738 | 05 | AR | MEDICAID | 11341402450 | 01 | AR-COMMERCIAL NUMBER | OTHER | 115712 | 01 | AR-COMMERCIAL NUMBER | OTHER | 129054514 (AR) | 05 | AR | MEDICAID | 138789752 | 05 | AR | MEDICAID | 145688732 | 05 | AR | MEDICAID | 129054514 | 05 | AR | MEDICAID | 145489757 | 05 | AR | MEDICAID | 138832757 | 05 | AR | MEDICAID | 140555765 | 05 | AR | MEDICAID | 013100P | 01 | AR-COMMERCIAL NUMBER | OTHER | 112135 | 01 | AR-COMMERCIAL NUMBER | OTHER | 129056732 | 05 | AR | MEDICAID |