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General NPI Number Information
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NPI Number | 1407012990
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Entity Type | Organization
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Legal Business Name | SUNDANCE REHABILITATION AGENCY, INC
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Dates
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Enumeration Date | 08/04/2008
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Last Update Date | 09/30/2009
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Provider Practice Location Address
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Address Line | 14525 CLAYTON RD APT #410
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City | BALLWIN
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State | MO
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Zip | 63011-2764
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Country | US
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Telephone | 636-527-3510
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Fax | 636-527-3510
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Provider Business Mailing Address
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Address Line | 101 SUN AVE NE COMPLIANCE DEPARTMENT
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-4373
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Country | US
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Telephone | 505-468-5604
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Fax | 505-468-4681
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Authorized Official
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Title or Position | PRESIDENT DIRECTOR
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Name | SUE GWYN
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Credential |
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Telephone | 505-821-3355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State | MO
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