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General NPI Number Information
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NPI Number | 1447760517
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Entity Type | Organization
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Legal Business Name | CHERRY STREET SERVICES, INC
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Dates
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Enumeration Date | 10/03/2017
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Last Update Date | 08/25/2023
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Provider Practice Location Address
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Address Line | 200 S BOLTWOOD ST
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City | HASTINGS
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State | MI
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Zip | 49058
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Country | US
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Telephone | 269-945-4220
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Fax | 269-945-4229
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Provider Business Mailing Address
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Address Line | 100 CHERRY ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-4526
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Country | US
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Telephone | 616-965-8209
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Fax | 269-945-4229
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | TASHA BLACKMON
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Credential |
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Telephone | 616-965-8215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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