Healthcare Provider Details

I. General information

NPI: 1871548842
Provider Name (Legal Business Name): SUNDANCE REHABILITATION AGENCY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 N PARK RD
HOLLYWOOD FL
33021-3744
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 954-961-9522
  • Fax: 954-961-9524
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberN/A
License Number State

VIII. Authorized Official

Name: SUE GWYN
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 703-684-1004