1508281411 NPI number — SUNDANCE REHABILITATION AGENCY, LLC

Table of content: (NPI 1508281411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508281411 NPI number — SUNDANCE REHABILITATION AGENCY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNDANCE REHABILITATION AGENCY, 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:
1508281411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNETT SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19348-3110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-815-8577
Provider Business Mailing Address Fax Number:
610-612-5123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
933 HIGHWAY 29 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30601-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-770-1705
Provider Business Practice Location Address Fax Number:
706-549-7786
Provider Enumeration Date:
02/28/2014

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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