Healthcare Provider Details

I. General information

NPI: 1396165601
Provider Name (Legal Business Name): CHERRY STREET SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY STREET
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

100 CHERRY STREET SE
GRAND RAPIDS MI
49503
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TASHA BLACKMON
Title or Position: CEO
Credential:
Phone: 616-776-2128