MEDICARE: CHERRY STREET SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	104100000X	Social Worker	MI
2	122300000X	Dentist
3	152W00000X	Optometrist
4	207Q00000X	Family Medicine Physician
5	207R00000X	Internal Medicine Physician
6	208000000X	Pediatrics Physician
7	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1942498670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRY STREET SERVICES INC

Provider Business Mailing Address
First Line	:	100 CHERRY ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4526
Country	:	US
Telephone Number	:	616-965-8200
Fax Number	:	616-940-5366

Provider Business Practice Location Address
First Line	:	1003 N LAFAYETTE ST
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-1168
Country	:	US
Telephone Number	:	616-225-9650
Fax Number	:	616-225-8525

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. TASHA BLACKMON
Credential	:
Telephone Number	:	616-965-8200

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	12/29/2021

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