Provider Demographics
NPI:1912367194
Name:GENTIVA
Entity Type:Organization
Organization Name:GENTIVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LAMISHA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-528-4037
Mailing Address - Street 1:52 DEERWOOD LN
Mailing Address - Street 2:11
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-6110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 CHURCH ST
Practice Address - Street 2:SUITE 11
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06103-1246
Practice Address - Country:US
Practice Address - Phone:860-528-4038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT251B00000X
CT1417097593310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1972605624Medicare Oscar/Certification