1093760928 NPI number — SUNDANCE REHABILITATION AGENCY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093760928 NPI number — SUNDANCE REHABILITATION AGENCY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNDANCE REHABILITATION AGENCY, INC.
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:
6
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:
1093760928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SUN AVE NE
Provider Second Line Business Mailing Address:
COMPLIANCE DEPARTMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-468-5604
Provider Business Mailing Address Fax Number:
505-468-4681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6336 CEDAR LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044-3897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-531-3402
Provider Business Practice Location Address Fax Number:
410-531-3402
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GWYN
Authorized Official First Name:
SUE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT DIRECTOR
Authorized Official Telephone Number:
617-646-5593

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)





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