Provider Demographics
NPI:1831468792
Name:SUNDANCE REHABILITATION
Entity Type:Organization
Organization Name:SUNDANCE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPY PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEREE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDDER
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:770-683-6854
Mailing Address - Street 1:110 EDGEWORTH RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6916
Mailing Address - Country:US
Mailing Address - Phone:770-683-6854
Mailing Address - Fax:770-252-0886
Practice Address - Street 1:110 EDGEWORTH RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-6916
Practice Address - Country:US
Practice Address - Phone:770-683-6854
Practice Address - Fax:770-252-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007514310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility