Provider Demographics
NPI:1104160662
Name:SUNDANCE REHABILITATION
Entity type:Organization
Organization Name:SUNDANCE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:410-479-2130
Mailing Address - Street 1:200 NORTHPOINTE CIR STE 302
Mailing Address - Street 2:
Mailing Address - City:SEVEN FIELDS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-7861
Mailing Address - Country:US
Mailing Address - Phone:800-815-8577
Mailing Address - Fax:
Practice Address - Street 1:520 KERR AVE
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-1343
Practice Address - Country:US
Practice Address - Phone:410-479-2130
Practice Address - Fax:410-479-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3417273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit