NPIMap

Organization Active NPI

Cherry Street Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Grand Rapids, MI
National Provider Identifier
1891867495
Registry record updated May 7, 2018
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
669 Stocking Ave NW
Grand Rapids, MI 49504-5176
Phone
(616) 235-1480
Fax
(616) 458-8102
NPI assigned
Nov 15, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 7, 2018

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) 965-8200

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical NeuropsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103G00000X
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X MI
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X
NutritionistGroup: 193200000X MULTI-SPECIALTY GROUP 133N00000X MI
Registered NurseGroup: 193200000X MULTI-SPECIALTY GROUP 163W00000X MI
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

669 Stocking Ave NW
Grand Rapids, MI 49504-5176

Mailing address

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

Other names 1

  • Westside 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
O20100818000970 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Grand Rapids, MI

Federally qualified health center certification: CCN 231853

Legal name
CHERRY STREET SERVICES INC
Doing business as
WESTSIDE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 24, 1996
Last certification
Jan 24, 1996
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1988 in MI
Enrollment address
669 Stocking Ave NW
Grand Rapids, MI 49504-5176

All disclosed owners & managing parties 18

Medicare enrollment files

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 1%
Ziyadah Shakir Individual Corporate DirectorBoard Member Sep 24, 2003 1%
Antonio Cardenas Individual Corporate DirectorBoard Member Apr 1, 2025
Jenny L Bush Individual Corporate OfficerCmo Mar 31, 2025
W-2 Managing EmployeeMD; Mar 31, 2025
Tasha Blackmon Individual Corporate OfficerCeo Mar 24, 2020
W-2 Managing Employee Mar 24, 2020
Cynthia Wagenhofer Individual Corporate OfficerCfo Sep 13, 2021
W-2 Managing Employee Sep 13, 2021
Margaret McGuiness Individual Corporate DirectorBoard Member Apr 1, 2014 1%
William Joure Individual Corporate OfficerCoo Jan 14, 2021
W-2 Managing EmployeeCoo Jan 14, 2021
David Smith Individual Corporate DirectorBoard Member Oct 1, 2011 1%
Barbara Wybrecht Individual Corporate DirectorBoard Member Sep 8, 2016 1%
Gwynn Bult Individual Corporate DirectorBoard Director-at-Large Apr 1, 2021
Willie Gholston Individual Corporate DirectorBoard Member Apr 1, 2025
Andrea Scott Individual Corporate DirectorBoard Member May 4, 2023
Kimberly Lavender Individual Corporate DirectorBoard Member Dec 1, 2007 1%
Leslie King Individual Corporate DirectorBoard Member Apr 21, 2023
Scott David Alfree Individual Corporate DirectorBoard Member Mar 1, 2013 1%
Shoran Williams Individual Corporate DirectorBoard- Vice President Feb 4, 2021
Kareem Scales Individual Corporate DirectorBoard Member Jan 4, 2024

All facility ownership & control disclosures 1

Medicare enrollment files

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

National Provider Directory

National Provider Directory

Owners & managing parties with NPI records 2

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

Owned or controlled facilities with NPI records 1

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

Other NPIs on the same Medicare enrollment 13

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

View all 13

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

Practitioners 58

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

View all 58

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
23D0959092Westside Health Center669 Stocking Ave NW, Grand Rapids, MI 49504Provider-performed microscopyMar 31, 2027

NPI Registry JSON

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

{
    "created_epoch": "1163548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1525651200000",
    "number": "1891867495",
    "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": "669 STOCKING AVE NW",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495045176",
            "telephone_number": "616-235-1480",
            "fax_number": "616-458-8102"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-15",
        "last_updated": "2018-05-07",
        "status": "A",
        "authorized_official_last_name": "BLACKMON",
        "authorized_official_first_name": "TASHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "616-965-8200"
    },
    "taxonomies": [
        {
            "code": "103G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Clinical Neuropsychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": "MI",
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "133N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nutritionist",
            "state": "MI",
            "license": null,
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Registered Nurse",
            "state": "MI",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Westside Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Westside Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

Verify at the official NPI Registry.