Healthcare Provider Details

I. General information

NPI: 1093760928
Provider Name (Legal Business Name): SUNDANCE REHABILITATION AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6336 CEDAR LN
COLUMBIA MD
21044-3897
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 410-531-3402
  • Fax: 410-531-3402
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: 617-646-5593