Basic Information
| Provider Information | |||||||||
| NPI: | 1447760517 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHERRY STREET SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CHERRY HEALTH - BARRY COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S BOLTWOOD ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490581993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699454220 | ||||||||
| FaxNumber: | 2699454229 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S BOLTWOOD ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699454220 | ||||||||
| FaxNumber: | 2699454229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2017 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONSTANTINO | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6167762128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHERRY STREET SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.