Basic Information
Provider Information | |||||||||
NPI: | 1689600371 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENTIVA CERTIFIED HEALTHCARE CORP. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTERWELL HOME HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6330 SPRINT PKWY STE 300 | ||||||||
Address2: |   | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662111157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9138142716 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1045 N 115TH ST STE 350 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681544415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023439433 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2006 | ||||||||
LastUpdateDate: | 09/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SKAGGS | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 9138142716 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 83186 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 945395002 | 05 | NE |   | MEDICAID | 1018667 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | GA0734 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 287038 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 67129 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 0450 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 0925024 | 05 | IA |   | MEDICAID | 0925024 | 05 | NE |   | MEDICAID | 013100P | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 6000478 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | ANC015 | 01 |   | NE-COMMERCIAL NUMBER | OTHER | 10662334 | 05 | NE |   | MEDICAID | 10183001 | 01 |   | NE-COMMERCIAL NUMBER | OTHER |