Healthcare Provider Details

I. General information

NPI: 1104160662
Provider Name (Legal Business Name): SUNDANCE REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 KERR AVE
DENTON MD
21629-1343
US

IV. Provider business mailing address

200 NORTHPOINTE CIR STE 302
SEVEN FIELDS PA
16046-7861
US

V. Phone/Fax

Practice location:
  • Phone: 410-479-2130
  • Fax: 410-479-3057
Mailing address:
  • Phone: 800-815-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License NumberA3417
License Number StateMD

VIII. Authorized Official

Name: MISS SUSAN P JORDAN
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 410-479-2130