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	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1629066238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HACKLEY COMMUNITY CARE CENTER INC

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

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	11/24/2010

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Directions to “HACKLEY COMMUNITY CARE CENTER INC ” Practice Location

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