Provider Demographics
NPI:1427438944
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:616-776-2129
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 1:1033 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1058
Practice Address - Country:US
Practice Address - Phone:616-965-8200
Practice Address - Fax:616-940-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTIN