Provider Demographics
NPI:1750336053
Name:SUNDANCE REHABILITATION LLC
Entity type:Organization
Organization Name:SUNDANCE REHABILITATION 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 1:101 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:610-347-4147
Practice Address - Street 1:102B KINGS WAY W
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2235
Practice Address - Country:US
Practice Address - Phone:856-582-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE REHABILITATION CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
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2671079OtherCIGNA
744645OtherAMERIHEALTH
C4306OtherAMERIHEALTH ADMIN.
OK8006OtherHEALTHNET
1090113OtherHORIZON MERCY
46101OtherORTHONET
SU343406OtherPENN BS
558970OtherAETNA US HEALTHCARE
QA9881OtherEMPIRE
QA9881OtherEMPIRE