Basic Information
| Provider Information | |||||||||
| NPI: | 1760437743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNDANCE REHABILITATION AGENCY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE STREET | ||||||||
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| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007288808 | ||||||||
| FaxNumber: | 6103474147 | ||||||||
| Practice Location | |||||||||
| Address1: | 11405 MEDLOCK BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702995049 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOIKA | ||||||||
| AuthorizedOfficialFirstName: | LOUISE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6109254088 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNDANCE REHABILITATION CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | N/A | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.