Provider Demographics
NPI:1932375763
Name:SUNDANCE REHABILITATION
Entity Type:Organization
Organization Name:SUNDANCE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MED CCC-SLP
Authorized Official - Phone:912-537-4813
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:1305 NORTHEAST MAIN STREET
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475
Mailing Address - Country:US
Mailing Address - Phone:912-537-4813
Mailing Address - Fax:912-537-6238
Practice Address - Street 1:1305 NORTHEAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30475
Practice Address - Country:US
Practice Address - Phone:912-537-4813
Practice Address - Fax:912-537-6238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006437310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility