Provider Demographics
NPI:1770841181
Name:SUNDANCE REHABILITATIOM
Entity Type:Organization
Organization Name:SUNDANCE REHABILITATIOM
Other - Org Name:ST JOSEPHS RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:T.P.M.
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:LAURIE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:920-982-9371
Mailing Address - Street 1:N359 MARTEN RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:WI
Mailing Address - Zip Code:54940-8736
Mailing Address - Country:US
Mailing Address - Phone:715-281-1827
Mailing Address - Fax:
Practice Address - Street 1:200 NORTHPOINTE CIR
Practice Address - Street 2:SUITE 302
Practice Address - City:SEVEN FIELDS
Practice Address - State:PA
Practice Address - Zip Code:16046-7861
Practice Address - Country:US
Practice Address - Phone:800-815-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE REHABILITATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1154-27314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility