Provider Demographics
NPI:1902024649
Name:CHERRY STREET SERVICES, INC
Entity Type:Organization
Organization Name:CHERRY STREET SERVICES, INC
Other - Org Name:
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 1:100 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4526
Practice Address - Country:US
Practice Address - Phone:616-776-2120
Practice Address - Fax:616-776-2122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX IDENTIFICATION NUMBER