Healthcare Provider Details

I. General information

NPI: 1427437326
Provider Name (Legal Business Name): HACKLEY COMMUNITY CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 LEAHY ST STE 103
MUSKEGON MI
49442-5538
US

IV. Provider business mailing address

2700 BAKER ST FL 3
MUSKEGON MI
49444-2157
US

V. Phone/Fax

Practice location:
  • Phone: 231-733-6901
  • Fax:
Mailing address:
  • Phone: 231-737-1335
  • Fax: 231-737-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: WAYNE KOHN
Title or Position: CMO
Credential: DO
Phone: 231-737-1335