Healthcare Provider Details

I. General information

NPI: 1780742015
Provider Name (Legal Business Name): CHERRY STREET SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax: 616-940-5366
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-940-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301036769
License Number StateMI

VIII. Authorized Official

Name: CHRIS SHEA
Title or Position: CEO
Credential:
Phone: 616-776-2120