Basic Information
| Provider Information | |||||||||
| NPI: | 1750336053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNDANCE REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE STREET | ||||||||
| Address2: | C/O AMY NUNEMAKER | ||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254560 | ||||||||
| FaxNumber: | 6103474147 | ||||||||
| Practice Location | |||||||||
| Address1: | 102B KINGS WAY W | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569884101 | ||||||||
| FaxNumber: | 8569888342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 1090113 | 01 | HORIZON MERCY | OTHER | C4306 | 01 | AMERIHEALTH ADMIN. | OTHER | 343406 | 01 | BC/BS | OTHER | OK8006 | 01 | HEALTHNET | OTHER | 46101 | 01 | ORTHONET | OTHER | SU343406 | 01 | PENN BS | OTHER | 744645 | 01 | AMERIHEALTH | OTHER | QA9881 | 01 | EMPIRE | OTHER | 2671079 | 01 | CIGNA | OTHER | 558970 | 01 | AETNA US HEALTHCARE | OTHER | 602638 | 01 | KEYSTONE HP EAST | OTHER |