Provider Demographics
NPI:1841245701
Name:SUNDANCE REHABILITATION LLC
Entity Type:Organization
Organization Name:SUNDANCE REHABILITATION LLC
Other - Org Name:SUNDANCE REHABILITATION AGENCY OF WISCONSIN
Other - Org Type:Doing Business As
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 ST
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:610-925-4560
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:3933 S PRAIRIE HILL LN
Practice Address - Street 2:C/O HICKORY PARK
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-2371
Practice Address - Country:US
Practice Address - Phone:414-546-3371
Practice Address - Fax:847-360-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41811700Medicaid
WI41811700Medicaid