Healthcare Provider Details

I. General information

NPI: 1154495901
Provider Name (Legal Business Name): CHERRY STREET SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 LAFAYETTE AVE NE
GRAND RAPIDS MI
49503-1628
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-742-9945
  • Fax: 616-742-9967
Mailing address:
  • Phone: 616-776-2370
  • Fax: 616-776-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS SHEA
Title or Position: CEO
Credential:
Phone: 616-776-2129