Basic Information
| Provider Information | |||||||||
| NPI: | 1740341395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNDANCE REHABILITATION AGENCY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUNDANCE REHABILITATION AGENCY OF MASSACHUSETTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 101 E STATE STREET | ||||||||
| Address2: | C/O AMY NUNEMAKER | ||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254560 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOPKINTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017481672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084351250 | ||||||||
| FaxNumber: | 5084352213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOIKA | ||||||||
| AuthorizedOfficialFirstName: | LOUISE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6109254088 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNDANCE REHABILITATION CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QR0400X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.