1962800680 NPI number — CHERRY STREET SERVICES INC

Table of content: (NPI 1962800680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962800680 NPI number — CHERRY STREET SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERRY STREET SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962800680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CHERRY ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-4526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-965-8200
Provider Business Mailing Address Fax Number:
616-940-5366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 W STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49058-9712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-945-4220
Provider Business Practice Location Address Fax Number:
269-945-4229
Provider Enumeration Date:
12/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SHEA
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
616-776-2129

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H80CS00770 . This is a "HRSA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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