NPIMap

Organization Active NPI

Hackley Community Care Center Inc

  • Federally Qualified Health Center (FQHC)
  • Muskegon, MI
National Provider Identifier
1356720262
Registry record updated May 26, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
HACKLEY COMMUNITY CARE CENTER INC
Practice address
376 E Apple Ave
Muskegon, MI 49442-3466
Phone
(231) 724-1335
NPI assigned
May 26, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Wayne Kohn, DO
Title
Cmo
Phone
(231) 737-1335

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

376 E Apple Ave
Muskegon, MI 49442-3466

Mailing address

2700 Baker St FL 3
Muskegon, MI 49444-2157
Phone (231) 737-1335

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040511001126 MI Part B Supplier - Clinic/Group Practice 8123015492 Receives reassigned benefits from 48 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Muskegon, MI
O20120328000679 MI Part A Provider - Federally Qualified Health Center (FQHC) 8123015492 1 other NPI on this enrollment
Practice locations: Muskegon, MI

Federally qualified health center certification: CCN 231976

Legal name
HACKLEY COMMUNITY CARE CENTER INC
Doing business as
HACKLEY COMMUNITY CARE CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 24, 2012
Last certification
Apr 24, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 23, 1991 in MI
Enrollment address
376 E Apple Ave
Muskegon, MI 49442-3466

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Javier Martinez Individual Corporate DirectorBoard Member Jan 24, 2012
Christopher Sandford Individual Corporate DirectorBoard Member Jan 24, 2012
Harold Santo Individual Corporate DirectorBoard Member Jan 24, 2012
Valerie Jan Blondin Individual Corporate OfficerCfo Jan 24, 2012
W-2 Managing EmployeeCfo Jan 24, 2012
Cheryl L Nebedum Individual Corporate DirectorBoard Member Jan 24, 2012
Stephanie Tanis Individual Corporate DirectorBoard Member Jan 24, 2012
Ashley Dowdell Individual Corporate Officer Jan 1, 2021
Gary M Lukkari Individual Corporate DirectorBoard Member Jan 24, 2012
Linda B Juarez Individual Corporate OfficerCeo Jan 24, 2012
Chris McGuigan Individual Corporate DirectorBoard Member Jan 24, 2012

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 2

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

NPI Registry JSON

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

{
    "created_epoch": "1432598400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1432598400000",
    "number": "1356720262",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2700 BAKER ST FL 3",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494442157",
            "telephone_number": "231-737-1335",
            "fax_number": "231-737-0534"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "376 E APPLE AVE",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494423466",
            "telephone_number": "231-724-1335"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HACKLEY COMMUNITY CARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-26",
        "last_updated": "2015-05-26",
        "status": "A",
        "authorized_official_last_name": "KOHN",
        "authorized_official_first_name": "WAYNE",
        "authorized_official_title_or_position": "CMO",
        "authorized_official_telephone_number": "231-737-1335",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "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": []
}

Other providers in Muskegon, MI

Sources for this page

Verify at the official NPI Registry.