Provider Demographics
NPI:1760437743
Name:SUNDANCE REHABILITATION AGENCY, LLC
Entity Type:Organization
Organization Name:SUNDANCE REHABILITATION AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SOIKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-925-4088
Mailing Address - Street 1:101 E STATE STREET
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:800-728-8808
Mailing Address - Fax:610-347-4147
Practice Address - Street 1:11405 MEDLOCK BRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1688
Practice Address - Country:US
Practice Address - Phone:470-299-5049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE REHABILITATION CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
116849Medicare Oscar/Certification