=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750336053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNDANCE REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 05/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102B KINGS WAY W
-----------------------------------------------------
City | SEWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08080-2235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-582-4500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E STATE STREET C/O AMY NUNEMAKER
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-925-4560
-----------------------------------------------------
Fax | 610-347-4147
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARL ANTHONY SHROM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-896-0422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State |
-----------------------------------------------------