Basic Information
| Provider Information | |||||||||
| NPI: | 1841245701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNDANCE REHABILITATION LLC | ||||||||
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| OtherOrganizationName: | SUNDANCE REHABILITATION AGENCY OF WISCONSIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254560 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 3933 S PRAIRIE HILL LN | ||||||||
| Address2: | C/O HICKORY PARK | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532282371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145463371 | ||||||||
| FaxNumber: | 8473609311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | SOIKA | ||||||||
| AuthorizedOfficialFirstName: | LOUISE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6109254088 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 41811700 | 05 | WI | MEDICAID |