Healthcare Provider Details

I. General information

NPI: 1407012990
Provider Name (Legal Business Name): SUNDANCE REHABILITATION AGENCY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14525 CLAYTON RD APT #410
BALLWIN MO
63011-2764
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 636-527-3510
  • Fax: 636-527-3510
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 Number
License Number StateMO

VIII. Authorized Official

Name: SUE GWYN
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 505-821-3355