Provider Demographics
NPI:1740341395
Name:SUNDANCE REHABILITATION AGENCY, LLC
Entity type:Organization
Organization Name:SUNDANCE REHABILITATION AGENCY, LLC
Other - Org Name:<UNAVAIL>
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:C/O AMY NUNEMAKER
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:
Practice Address - Street 1:50 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPKINTON
Practice Address - State:MA
Practice Address - Zip Code:01748-1672
Practice Address - Country:US
Practice Address - Phone:508-435-1250
Practice Address - Fax:508-435-2213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE REHABILITATION CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MA261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
226543Medicare Oscar/Certification