NPIMap

Organization Active NPI

Hackley Community Care Center Inc

  • Federally Qualified Health Center (FQHC)
  • Muskegon, MI
National Provider Identifier
1508245408
Registry record updated Feb 13, 2018
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
80 W Southern Ave
Muskegon, MI 49441-2541
Phone
(231) 733-6680
NPI assigned
May 26, 2015
Last updated
Feb 13, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 13, 2018

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

Authorized official

Name
Wayne Kohn, DONPI 1679545115
Title
Cmo
Phone
(231) 737-1335

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

80 W Southern Ave
Muskegon, MI 49441-2541

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
1508245408OtherMINPI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110608000847 MI Part A Provider - Federally Qualified Health Center (FQHC) 8123015492 Practice locations: Muskegon, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508245408. Details of each certification follow.

Federally qualified health center certification: CCN 231961

Legal name
HACKLEY COMMUNITY CARE CENTER INC
Doing business as
MUSKEGON PUBLIC HIGH SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 29, 2011
Last certification
Jul 29, 2011
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Oct 23, 1991 in MI
Enrollment address
80 W Southern Ave
Muskegon, MI 49441-2541

Other NPIs with the same Medicare PAC ID 7

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

National Provider Directory

National Provider Directory
Tax ID family
Hackley Community Care31 organizations share this tax ID, including this one

Other organizations with this tax ID 30

Organizations that report the same tax identification number in the National Provider Directory.

View all 30

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Christopher Sandford Individual Corporate Director May 25, 2011
Harold Santo Individual Corporate Director May 25, 2011
Valerie Jan Blondin Individual Corporate OfficerCfo Jan 24, 2012
W-2 Managing EmployeeCeo Jan 24, 2012 1%
Cheryl L Nebedum Individual Corporate Director May 25, 2011
Stephanie Tanis Individual Corporate Director May 25, 2011
Ashley Dowdell Individual Corporate OfficerChief Strategy & Compliance Officer Dec 7, 2020
W-2 Managing EmployeeChief Strategy & Compliance Officer Dec 7, 2020
Gary M Lukkari Individual Corporate Director May 25, 2011
Linda B Juarez Individual Corporate DirectorCeo Jan 1, 1994
Chris McGuigan Individual Corporate Director May 25, 2011

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 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

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": "1518480000000",
    "number": "1508245408",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "80 W SOUTHERN AVE",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494412541",
            "telephone_number": "231-733-6680"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HACKLEY COMMUNITY CARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-26",
        "last_updated": "2018-02-13",
        "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": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "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": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1508245408",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Muskegon, MI

Sources for this page

Verify at the official NPI Registry.