Provider Demographics
NPI:1407889678
Name:CHEYENNE TRACE, LLC
Entity Type:Organization
Organization Name:CHEYENNE TRACE, LLC
Other - Org Name:CHEYENNE TRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLSTED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-448-3700
Mailing Address - Street 1:420 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5412
Mailing Address - Country:US
Mailing Address - Phone:731-661-9888
Mailing Address - Fax:
Practice Address - Street 1:14800 ST. MARY'S LANE
Practice Address - Street 2:SUITE 175
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079
Practice Address - Country:US
Practice Address - Phone:832-448-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL0000000124310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility