Provider Demographics
NPI:1396160339
Name:CHEYENNE ENTERPRISES
Entity type:Organization
Organization Name:CHEYENNE ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:B
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-253-7795
Mailing Address - Street 1:6100 N KEYSTONE AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2452
Mailing Address - Country:US
Mailing Address - Phone:317-253-7795
Mailing Address - Fax:317-253-7798
Practice Address - Street 1:6100 N KEYSTONE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2452
Practice Address - Country:US
Practice Address - Phone:317-253-7795
Practice Address - Fax:317-253-7798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003529B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953660Medicaid