Healthcare Provider Details

I. General information

NPI: 1871622738
Provider Name (Legal Business Name): CHEYENNE VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 PEARL DR # 4280
COLORADO SPRINGS CO
80918-2751
US

IV. Provider business mailing address

6275 LEHMAN DR
COLORADO SPRINGS CO
80918-1433
US

V. Phone/Fax

Practice location:
  • Phone: 719-536-9763
  • Fax:
Mailing address:
  • Phone: 719-592-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0620
License Number StateCO

VIII. Authorized Official

Name: MS. MARY L DICE
Title or Position: CFO
Credential:
Phone: 719-572-7447