Healthcare Provider Details

I. General information

NPI: 1972029353
Provider Name (Legal Business Name): CHERUB ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5413 S WESTNEDGE AVE STE D-E
PORTAGE MI
49002-0453
US

IV. Provider business mailing address

5413 S WESTNEDGE AVE STE D-E
PORTAGE MI
49002-0453
US

V. Phone/Fax

Practice location:
  • Phone: 269-459-6464
  • Fax: 269-348-0079
Mailing address:
  • Phone: 269-459-6464
  • Fax: 269-348-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELLEN KLUCK
Title or Position: MANAGER
Credential:
Phone: 269-459-6464