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General NPI Number Information
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NPI Number | 1902144074
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Entity Type | Organization
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Legal Business Name | SUNDANCE SERVICES CORP
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Dates
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Enumeration Date | 01/24/2013
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Last Update Date | 01/24/2013
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Provider Practice Location Address
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Address Line | 107 E BECKERT RD
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City | NEW LONDON
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State | WI
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Zip | 54961-2509
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Country | US
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Telephone | 920-982-5354
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Fax | 920-982-9149
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Provider Business Mailing Address
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Address Line | 107 E BECKERT RD
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City | NEW LONDON
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State | WI
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Zip | 54961-2509
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Country | US
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Telephone | 920-982-5354
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Fax | 920-982-9149
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Authorized Official
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Title or Position | AREA MANAGER
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Name | MRS. LORI FREISINGER
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Credential | O.T.
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Telephone | 414-531-5226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 3026-154
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License Number State | WI
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