Basic Information
| Provider Information | |||||||||
| NPI: | 1235594920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHERRY HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SHELDON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167762340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 SHELDON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167762340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2015 | ||||||||
| LastUpdateDate: | 12/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | BARANOWSKI | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLEY | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTAL HYGIENIST | ||||||||
| AuthorizedOfficialTelephone: | 6167762340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RDH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | 2902009418 | MI | Y | Respite Care Facility | Respite Care |
ID Information
| ID | Type | State | Issuer | Description | 2902009418 | 05 | MI | MEDICAID |