Healthcare Provider Details

I. General information

NPI: 1902144074
Provider Name (Legal Business Name): SUNDANCE SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E BECKERT RD
NEW LONDON WI
54961-2509
US

IV. Provider business mailing address

107 E BECKERT RD
NEW LONDON WI
54961-2509
US

V. Phone/Fax

Practice location:
  • Phone: 920-982-5354
  • Fax: 920-982-9149
Mailing address:
  • Phone: 920-982-5354
  • Fax: 920-982-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3026-154
License Number StateWI

VIII. Authorized Official

Name: MRS. LORI FREISINGER
Title or Position: AREA MANAGER
Credential: O.T.
Phone: 414-531-5226