Healthcare Provider Details

I. General information

NPI: 1922361310
Provider Name (Legal Business Name): SUNDANCE REHABILITATION AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 HAMPTON RD
EXETER NH
03833-4859
US

IV. Provider business mailing address

101 SUN AVE NE DEPT REHAB
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 603-772-5251
  • Fax: 603-778-1024
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 State

VIII. Authorized Official

Name: SUSAN GWYN
Title or Position: PRESIDENT
Credential:
Phone: 617-279-0201