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General NPI Number Information
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NPI Number | 1912367194
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Entity Type | Organization
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Legal Business Name | GENTIVA
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Dates
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Enumeration Date | 03/01/2016
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Last Update Date | 03/01/2016
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Provider Practice Location Address
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Address Line | 20 CHURCH ST SUITE 11
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City | HARTFORD
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State | CT
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Zip | 06103-1246
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Country | US
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Telephone | 860-528-4038
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Fax |
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Provider Business Mailing Address
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Address Line | 52 DEERWOOD LN 11
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City | WATERBURY
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State | CT
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Zip | 06704-6110
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICAL SUPERVISOR
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Name | LAMISHA S CORLEY
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Credential | M.D.
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Telephone | 860-528-4037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 1417097593
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | CT
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