MEDICARE: HACKLEY COMMUNITY CARE CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	207Q00000X	Family Medicine Physician
3	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1427437326	OTHER		NPI

General Provider Information

NPI Number	:	1427437326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HACKLEY COMMUNITY CARE CENTER INC

Provider Business Mailing Address
First Line	:	2700 BAKER ST FL 3
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-1335
Fax Number	:	231-737-0534

Provider Business Practice Location Address
First Line	:	1675 LEAHY ST STE 103
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5538
Country	:	US
Telephone Number	:	231-733-6901
Fax Number	:

Authorized Official
Title or Position	:	CMO
Name	:	WAYNE KOHN
Credential	:	DO
Telephone Number	:	231-737-1335

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	06/30/2015

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Directions to “HACKLEY COMMUNITY CARE CENTER INC ” Practice Location

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