NPIMap

Organization Active NPI

Hackley Community Care Center Inc

  • Federally Qualified Health Center (FQHC)
  • Muskegon, MI
National Provider Identifier
1629066238
Registry record updated Nov 24, 2010
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
2700 Baker St
3Rd Floor
Muskegon, MI 49444-2157
Phone
(231) 737-1335
Fax
(231) 737-0534
NPI assigned
Oct 7, 2005
Last updated
Nov 24, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 24, 2010

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

Authorized official

Name
Wayne H Kohn, DONPI 1679545115
Title
Medical Director
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

2700 Baker St
3Rd Floor
Muskegon, MI 49444-2157

Mailing address

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI3 enrollments

Enrollment records 3

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
Practice locations: Muskegon, MI
O20101105000714 MI Part A Provider - Federally Qualified Health Center (FQHC) 8123015492 1 other NPI on this enrollment
Practice locations: Muskegon, MI
O20120328000679 MI Part A Provider - Federally Qualified Health Center (FQHC) 8123015492 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Muskegon, MI

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1629066238. Details of each certification follow.

Federally qualified health center certification: CCN 231858

Legal name
HACKLEY COMMUNITY CARE CENTER INC
Doing business as
HACKLEY COMMUNITY CARE CENTER MOBILE DENTAL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 16, 1996
Last certification
Jul 16, 1996
Ownership / control type
For profit – partnership
Organization structure
CorporationProprietary
Incorporated
Oct 23, 1991 in MI
Enrollment address
2700 Baker St 3Rd Floor
Muskegon, MI 49444-2157

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 6

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 11

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 Aug 5, 2010
Corporate DirectorBoard Member Jan 24, 2012
Harold Santo Individual Corporate Director Aug 5, 2010
Corporate DirectorBoard Member Jan 24, 2012
Leslie N Kingsley Individual Corporate OfficerCmo Dec 1, 2020
Valerie Jan Blondin Individual Corporate OfficerCfo Jan 24, 2012
W-2 Managing Employee Jan 24, 2012
W-2 Managing EmployeeCfo Jan 24, 2012
Cheryl L Nebedum Individual Corporate Director Aug 5, 2010
Corporate DirectorBoard Member Jan 24, 2012
Stephanie Tanis Individual Corporate Director Aug 5, 2010
Corporate DirectorBoard Member Jan 24, 2012
Ashley Dowdell Individual Corporate Officer Jan 1, 2021
W-2 Managing EmployeeChief Strategy & Compliance Officer Dec 7, 2020
Gary M Lukkari Individual Corporate Director Aug 5, 2010
Corporate DirectorBoard Member Jan 24, 2012
Linda B Juarez Individual Corporate Director Nov 8, 2010
Corporate OfficerCeo Jan 24, 2012
Chris McGuigan Individual Corporate Director Aug 5, 2010
Corporate DirectorBoard Member Jan 24, 2012
Javier Martinez Individual Corporate DirectorBoard Member Jan 24, 2012

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 50

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.

View all 50

NPI Registry JSON

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

{
    "created_epoch": "1128643200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1290556800000",
    "number": "1629066238",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2700 BAKER ST",
            "address_2": "3RD FLOOR",
            "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": "2700 BAKER ST",
            "address_2": "3RD FLOOR",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494442157",
            "telephone_number": "231-737-1335",
            "fax_number": "231-737-0534"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HACKLEY COMMUNITY CARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-07",
        "last_updated": "2010-11-24",
        "status": "A",
        "authorized_official_last_name": "KOHN",
        "authorized_official_first_name": "WAYNE",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "231-737-1335",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Muskegon, MI

Sources for this page

Verify at the official NPI Registry.