Provider Demographics
NPI:1063586816
Name:CHERRY STREET SERVICES, INC.
Entity type:Organization
Organization Name:CHERRY STREET SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-776-2120
Mailing Address - Street 1:100 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4526
Mailing Address - Country:US
Mailing Address - Phone:616-965-8200
Mailing Address - Fax:616-940-5366
Practice Address - Street 1:1215 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3849
Practice Address - Country:US
Practice Address - Phone:616-459-9468
Practice Address - Fax:616-459-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231857OtherFACILITY NUMBER
MI231857Medicare Oscar/Certification