1750336053 NPI number — SUNDANCE REHABILITATION LLC

Table of content: (NPI 1750336053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750336053 NPI number — SUNDANCE REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNDANCE REHABILITATION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750336053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E STATE STREET
Provider Second Line Business Mailing Address:
C/O AMY NUNEMAKER
Provider Business Mailing Address City Name:
KENNETT SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19348-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-925-4560
Provider Business Mailing Address Fax Number:
610-347-4147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102B KINGS WAY W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08080-2235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-582-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHROM
Authorized Official First Name:
CARL
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
215-896-0422

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 343406 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 602638 . This is a "KEYSTONE HP EAST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2671079 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 744645 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: C4306 . This is a "AMERIHEALTH ADMIN." identifier . This identifiers is of the category "OTHER".
  • Identifier: OK8006 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1090113 . This is a "HORIZON MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 46101 . This is a "ORTHONET" identifier . This identifiers is of the category "OTHER".
  • Identifier: SU343406 . This is a "PENN BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 558970 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: QA9881 . This is a "EMPIRE" identifier . This identifiers is of the category "OTHER".




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