Basic Information
| Provider Information | |||||||||
| NPI: | 1861428575 | ||||||||
| 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: | 804 E JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747434222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803268376 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKAGGS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9138142716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100260400U | 05 | OK | MEDICAID | 100260400 E | 05 | OK | MEDICAID | 100260400L | 05 | OK | MEDICAID | B45126453331 | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400C | 01 | OK-COMMERCIAL NUMBER | OTHER | 2366169 | 01 | OK-COMMERCIAL NUMBER | OTHER | 7559146 | 01 | OK-COMMERCIAL NUMBER | OTHER | ANC015 | 01 | OK-COMMERCIAL NUMBER | OTHER | 013100P | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400A | 05 | OK | MEDICAID | 100260400B | 01 | OK-COMMERCIAL NUMBER | OTHER | 000377146002 | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400E | 05 | OK | MEDICAID | 1020616 | 01 | OK-COMMERCIAL NUMBER | OTHER | 17029 | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400M | 05 | OK | MEDICAID | 377146 | 01 | OK-COMMERCIAL NUMBER | OTHER |