Provider Demographics
NPI:1124073101
Name:SUNDANCE REHABILITATION AGENCY, INC.
Entity type:Organization
Organization Name:SUNDANCE REHABILITATION AGENCY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HIRSCHFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-925-4025
Mailing Address - Street 1:6549 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0065
Mailing Address - Country:US
Mailing Address - Phone:800-815-8577
Mailing Address - Fax:505-468-9233
Practice Address - Street 1:728 KLUMAC RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-5720
Practice Address - Country:US
Practice Address - Phone:704-797-9857
Practice Address - Fax:704-636-7286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE REHABILITATION CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
346632Medicare Oscar/Certification