Basic Information
| Provider Information | |||||||||
| NPI: | 1902833825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENTIVA HEALTH SERVICES (USA), LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINDRED AT HOME V | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 FOSTER ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662132696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 804 E JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747434222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803268376 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHWARTZ | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9138142288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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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 | 100260400E | 05 | OK | MEDICAID | 17029 | 01 | OK-COMMERCIAL NUMBER | OTHER | B45126453331 | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400C | 01 | OK-COMMERCIAL NUMBER | OTHER | 112645333186 | 01 | OK-CHAMPUS | OTHER | 100260400A | 05 | OK | MEDICAID | 100260400M | 05 | OK | MEDICAID | 1020616 | 01 | OK-COMMERCIAL NUMBER | OTHER | 000377146002 | 01 | OK-COMMERCIAL NUMBER | OTHER | 112645333 | 01 | OK-COMMERCIAL NUMBER | OTHER | 2366169 | 01 | OK-COMMERCIAL NUMBER | OTHER | GA0177 | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400B | 01 | OK-COMMERCIAL NUMBER | OTHER | ANC015 | 01 | OK-COMMERCIAL NUMBER | OTHER | 013100P | 01 | OK-COMMERCIAL NUMBER | OTHER | 100260400L | 05 | OK | MEDICAID | 377146 | 01 | OK-COMMERCIAL NUMBER | OTHER | 7559146 | 01 | OK-COMMERCIAL NUMBER | OTHER |