Provider Demographics
NPI:1508281411
Name:SUNDANCE REHABILITATION AGENCY, LLC
Entity type:Organization
Organization Name:SUNDANCE REHABILITATION AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SHROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-896-0422
Mailing Address - Street 1:100 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3110
Mailing Address - Country:US
Mailing Address - Phone:800-815-8577
Mailing Address - Fax:610-612-5123
Practice Address - Street 1:933 HIGHWAY 29 N
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1530
Practice Address - Country:US
Practice Address - Phone:706-770-1705
Practice Address - Fax:706-549-7786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-28
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation