Healthcare Provider Details

I. General information

NPI: 1508281411
Provider Name (Legal Business Name): SUNDANCE REHABILITATION AGENCY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 HIGHWAY 29 N
ATHENS GA
30601-1530
US

IV. Provider business mailing address

100 E STATE ST
KENNETT SQUARE PA
19348-3110
US

V. Phone/Fax

Practice location:
  • Phone: 706-770-1705
  • Fax: 706-549-7786
Mailing address:
  • Phone: 800-815-8577
  • Fax: 610-612-5123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARL ANTHONY SHROM
Title or Position: CEO
Credential:
Phone: 215-896-0422