Provider Demographics
NPI:1902144074
Name:SUNDANCE SERVICES CORP
Entity Type:Organization
Organization Name:SUNDANCE SERVICES CORP
Other - Org Name:GENESIS REHAB SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AREA MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:FREISINGER
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:414-531-5226
Mailing Address - Street 1:107 E BECKERT RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2509
Mailing Address - Country:US
Mailing Address - Phone:920-982-5354
Mailing Address - Fax:920-982-9149
Practice Address - Street 1:107 E BECKERT RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2509
Practice Address - Country:US
Practice Address - Phone:920-982-5354
Practice Address - Fax:920-982-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3026-154314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3026-154OtherSTATE OF WISCONSIN - DSPS LICENSE RENEWAL
WI42591500Medicaid