NPIMap

Organization Active NPI

Cherry Street Services Inc

  • Federally Qualified Health Center (FQHC)
  • Wyoming, MI
National Provider Identifier
1104423508
Registry record updated Aug 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CHERRY STREET SERVICES INC
Practice address
100 Wexford St SE RM 214
Wyoming, MI 49548-2212
Phone
(616) 252-2070
NPI assigned
Oct 8, 2020
Organization subpart
Yes
Parent organization
CHERRY STREET SERVICES INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 25, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tasha Blackmon
Title
Ceo
Phone
(616) 965-8215

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Medical Specialty Clinic/Center 261QM2500X

Addresses

Primary practice location

100 Wexford St SE RM 214
Wyoming, MI 49548-2212

Mailing address

100 Cherry St SE
Grand Rapids, MI 49503-4526
Phone (616) 965-8200

Other names 1

  • Godwin Heights Middle School Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201019002077 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Grand Rapids, MI

Federally qualified health center certification: CCN 231165

Legal name
CHERRY STREET SERVICES INC
Doing business as
GODWIN HEIGHTS MIDDLE SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 11, 2020
Last certification
Nov 11, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 29, 2020 in MI
Enrollment address
100 Wexford St SE RM 214
Grand Rapids, MI 49548-2212

Other NPIs with the same Medicare PAC ID 19

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 19

National Provider Directory

National Provider Directory
Tax ID family
Employee Assistance Center Fulton29 organizations share this tax ID, including this one
Part of
Employee Assistance Center Fulton

Other organizations with this tax ID 28

Organizations that report the same tax identification number in the National Provider Directory.

View all 28

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Elizabeth Triezenberg Individual Corporate DirectorBoard Member Aug 4, 2016
Ziyadah Shakir Individual Corporate DirectorBoard Member Sep 29, 2020
Antonio Cardenas Individual Corporate DirectorBoard Member Apr 1, 2025
Jenny L Bush Individual Corporate OfficerCmo Mar 31, 2025
W-2 Managing Employee Mar 31, 2025
Tasha Blackmon Individual Corporate OfficerCeo Sep 29, 2020
Cynthia Wagenhofer Individual Corporate OfficerCfo Sep 13, 2021
W-2 Managing EmployeeCfo Sep 13, 2021
Margaret McGuiness Individual Corporate DirectorBoard Member Sep 29, 2020
William Joure Individual Corporate OfficerCoo Jan 4, 2021
W-2 Managing EmployeeCoo Jan 4, 2021
David Smith Individual Corporate DirectorBoard Member Sep 29, 2020
Barbara Wybrecht Individual Corporate DirectorBoard Member Sep 29, 2020
Gwynn Bult Individual Corporate DirectorBoard Member Apr 1, 2021
Willie Gholston Individual Corporate DirectorBoard Member Apr 1, 2025
Andrea Scott Individual Corporate DirectorBoard Treasurer May 4, 2023
Kimberly Lavender Individual Corporate DirectorBoard Member Sep 29, 2020
Leslie King Individual Corporate DirectorBoard Member Apr 7, 2022
Scott David Alfree Individual Corporate DirectorBoard Member Sep 29, 2020
Shoran Williams Individual Corporate DirectorBoard Vice President Feb 4, 2021
Kareem Scales Individual Corporate DirectorBoard Member Jan 4, 2024

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Barry Community Health CenterHastings, MI, CCN 231122 Federally qualified health center Operational/Managerial Control Dec 1, 2017

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 58

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 58

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1602115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692921600000",
    "number": "1104423508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CHERRY ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495034526",
            "telephone_number": "616-965-8200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 WEXFORD ST SE RM 214",
            "city": "WYOMING",
            "state": "MI",
            "postal_code": "495482212",
            "telephone_number": "616-252-2070"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHERRY STREET SERVICES INC",
        "enumeration_date": "2020-10-08",
        "last_updated": "2023-08-25",
        "certification_date": "2023-08-25",
        "status": "A",
        "authorized_official_last_name": "BLACKMON",
        "authorized_official_first_name": "TASHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "616-965-8215"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Godwin Heights Middle School",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Godwin Heights Middle School",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wyoming, MI

Sources for this page

Verify at the official NPI Registry.