Healthcare Provider Details

I. General information

NPI: 1619485398
Provider Name (Legal Business Name): HACKLEY COMMUNITY CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 S WOLF LAKE RD STE A
MUSKEGON MI
49442-3033
US

IV. Provider business mailing address

2700 BAKER ST FL 3
MUSKEGON MI
49444-2157
US

V. Phone/Fax

Practice location:
  • Phone: 231-788-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JO ANN PAPROCKI
Title or Position: BILLING MANAGER
Credential:
Phone: 231-733-6804