NPIMap

Organization Active NPI

Cherry Street Services, Inc.

Doing business as Lakeside Clubhouse

  • Clinical Social Worker
  • Holland, MI
National Provider Identifier
1215414800
Registry record updated Jul 30, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
Legal business name
CHERRY STREET SERVICES, INC.
Doing business as
Lakeside Clubhouse
Practice address
490 Century LN
Holland, MI 49423
Phone
(616) 965-8380
Fax
(616) 965-8381
NPI assigned
Jul 26, 2018
Last updated
Jul 30, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
CHERRY STREET SERVICES, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 30, 2018

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

Authorized official

Name
Linda M Constantino
Title
Cfo
Phone
(616) 776-2128

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social Worker 1041C0700X NU Primary

Addresses

Primary practice location

490 Century LN
Holland, MI 49423

Mailing address

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

Other names 1

  • Lakeside Clubhouse Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230111002446 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Holland, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1215414800. Details of each certification follow.

Federally qualified health center certification: CCN 231196

Legal name
CHERRY STREET SERVICES INC
Doing business as
LAKESIDE CLUBHOUSE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 3, 2023
Last certification
Apr 3, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 21, 1988 in MI
Enrollment address
490 Century LN
Holland, MI 49423-2220

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

Locations

490 Century Ln
Holland, MI 49423
Phone (616) 594-0810

Ownership & related parties

All disclosed owners & managing parties 17

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 Jan 2, 2019
Allen Tenhoor Individual Corporate DirectorBoard Member Jan 2, 2019
Ziyadah Shakir Individual Corporate DirectorBoard Member Jan 2, 2019
Allison Swets Individual Corporate DirectorBoard Member Jan 2, 2019
Esperanza Degnan Individual Corporate DirectorBoard Member Jan 2, 2019
Richard Stevens Individual Corporate DirectorBoard Member Jan 2, 2019
Tasha Blackmon Individual Corporate OfficerCeo Jan 2, 2019
W-2 Managing EmployeeCeo Jan 2, 2019
Harold Overly Individual Corporate DirectorBoard Member Jan 2, 2019
Margaret McGuiness Individual Corporate DirectorBoard Member Jan 2, 2019
David Smith Individual Corporate DirectorBoard Member Jan 2, 2019
Barbara Wybrecht Individual Corporate DirectorBoard Member Jan 2, 2019
Shaloria Mitchell Individual Corporate DirectorBoard Member Jan 2, 2019
Angela Vander Hulst Individual Corporate DirectorBoard Member Jan 2, 2019
Francena Purchase-Owens Individual Corporate DirectorBoard Member Jan 2, 2019
Kimberly Lavender Individual Corporate DirectorBoard Member Jan 2, 2019
Scott David Alfree Individual Corporate DirectorBoard Member Jan 2, 2019
Carol Dickinson Individual Corporate DirectorBoard Member Jan 2, 2019

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.

NPI Registry JSON

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

{
    "created_epoch": "1532563200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1532908800000",
    "number": "1215414800",
    "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": "490 CENTURY LN",
            "city": "HOLLAND",
            "state": "MI",
            "postal_code": "49423",
            "telephone_number": "616-965-8380",
            "fax_number": "616-965-8381"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHERRY STREET SERVICES, INC.",
        "enumeration_date": "2018-07-26",
        "last_updated": "2018-07-30",
        "status": "A",
        "authorized_official_last_name": "CONSTANTINO",
        "authorized_official_first_name": "LINDA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "616-776-2128"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeside Clubhouse",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Holland, MI

Sources for this page

Verify at the official NPI Registry.