Provider Demographics
NPI:1407012990
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:PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:GWYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-821-3355
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:14525 CLAYTON RD
Practice Address - Street 2:APT #410
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2764
Practice Address - Country:US
Practice Address - Phone:636-527-3510
Practice Address - Fax:636-527-3510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE REHABILITATION CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-04
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation