Provider Demographics
NPI:1477670081
Name:GENTIVA
Entity Type:Organization
Organization Name:GENTIVA
Other - Org Name:MID-SOUTH
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS, PT, CMT
Authorized Official - Phone:205-914-8588
Mailing Address - Street 1:2034 FOREST LAKES LN
Mailing Address - Street 2:
Mailing Address - City:STERRETT
Mailing Address - State:AL
Mailing Address - Zip Code:35147-8151
Mailing Address - Country:US
Mailing Address - Phone:205-914-8588
Mailing Address - Fax:
Practice Address - Street 1:2200 RIVERCHASE CTR STE 700
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-2915
Practice Address - Country:US
Practice Address - Phone:205-739-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty