=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407889678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHEYENNE TRACE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14800 ST. MARY'S LANE SUITE 175
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-448-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 CHEYENNE DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-661-9888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAKE HALLSTED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-448-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ACL0000000124
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------