Healthcare Provider Details

I. General information

NPI: 1912367194
Provider Name (Legal Business Name): GENTIVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CHURCH ST SUITE 11
HARTFORD CT
06103-1246
US

IV. Provider business mailing address

52 DEERWOOD LN 11
WATERBURY CT
06704-6110
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-4038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1417097593
License Number StateCT

VIII. Authorized Official

Name: LAMISHA S CORLEY
Title or Position: CLINICAL SUPERVISOR
Credential: M.D.
Phone: 860-528-4037