NPIMap

Organization Active NPI

Cherry Street Services, Inc.

Doing business as Ottawa Hills High School Health Center

  • Federally Qualified Health Center (FQHC)
  • Grand Rapids, MI
National Provider Identifier
1124187471
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.
Doing business as
Ottawa Hills High School Health Center
Practice address
2055 Rosewood Ave SE
Grand Rapids, MI 49506-5248
Phone
(616) 776-5110
Fax
(616) 776-5111
NPI assigned
Dec 6, 2006
Last updated
Aug 25, 2023By the provider in NPPES
Organization subpart
No

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 5

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Social Worker 104100000X MI
Dentist 122300000X NU
Family Medicine Physician 207Q00000X NU
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

2055 Rosewood Ave SE
Grand Rapids, MI 49506-5248

Mailing address

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

Other names 1

  • Ottawa Hills High School Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040804000274 MI Part B Supplier - Clinic/Group Practice 6800707647 Receives reassigned benefits from 133 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Grand Rapids, MI
O20131205001914 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Grand Rapids, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124187471. Details of each certification follow.

Federally qualified health center certification: CCN 231909

Legal name
CHERRY STREET SERVICES INC
Doing business as
OTTAWA HILLS HIGH SCHOOL HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 23, 2006
Last certification
Jan 23, 2006
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1988 in MI
Enrollment address
2055 Rosewood Ave SE
Grand Rapids, MI 49506-5248
Related CCNs
231809

Facilities connected through Provider of Services related, parent or unit certification numbers.

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

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D1045434Ottawa Hills High School Health Center2055 Rosewood St SE, Grand Rapids, MI 49506Certificate of waiverOct 18, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 16

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 Sep 8, 2016
Allen Tenhoor Individual Corporate DirectorBoard Member May 1, 2006
Allison Swets Individual Corporate DirectorBoard Member Oct 1, 2011
Esperanza Degnan Individual Corporate Director Oct 27, 2023
Richard Stevens Individual Corporate DirectorBoard Member Dec 1, 2002
Tasha Blackmon Individual Corporate OfficerCeo Apr 1, 2018
W-2 Managing EmployeeChief Executive Officer Apr 1, 2018
Margaret McGuiness Individual Corporate DirectorBoard Member Apr 1, 2013
David Smith Individual Corporate DirectorBoard Member Oct 1, 2011
Barbara Wybrecht Individual Corporate DirectorBoard Member Sep 8, 2016
Gwynn Bult Individual Corporate DirectorBoard Member Oct 27, 2023
Evelyn Esparza-Gonzales Individual Corporate DirectorBoard Member Oct 27, 2023
Francena Purchase-Owens Individual Corporate DirectorBoard Member Oct 27, 2023
Kimberly Lavender Individual Corporate DirectorBoard Member Dec 1, 2007
Leslie King Individual Corporate DirectorBoard Member Oct 27, 2023
Scott David Alfree Individual Corporate DirectorBoard Member Mar 1, 2013
Carol Dickinson Individual Corporate DirectorBoard Member Apr 1, 2013

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 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1165363200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692921600000",
    "number": "1124187471",
    "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",
            "fax_number": "616-940-5366"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2055 ROSEWOOD AVE SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495065248",
            "telephone_number": "616-776-5110",
            "fax_number": "616-776-5111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-06",
        "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": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "MI",
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ottawa Hills High School Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ottawa Hills High School Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

Verify at the official NPI Registry.