Healthcare Provider Details

I. General information

NPI: 1124187471
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: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 ROSEWOOD AVE SE
GRAND RAPIDS MI
49506-5248
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-776-5110
  • Fax: 616-776-5111
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-940-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: TASHA BLACKMON
Title or Position: CEO
Credential:
Phone: 616-965-8215