NPIMap

Organization Active NPI

Hackley Community Care Center Inc

Doing business as Oakridge School District SBHC

  • Federally Qualified Health Center (FQHC)
  • Muskegon, MI
National Provider Identifier
1699154500
Registry record updated Nov 24, 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
Doing business as
Oakridge School District SBHC
Practice address
251 S Wolf Lake Rd
Muskegon, MI 49442-3029
Phone
(231) 788-7461
NPI assigned
May 26, 2015
Last updated
Nov 24, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 24, 2015

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
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Professional Counselor 101YP2500X
Family Medicine Physician 207Q00000X

Addresses

Primary practice location

251 S Wolf Lake Rd
Muskegon, MI 49442-3029

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
1699154500OtherMINPI

Other names 1

  • Oakridge School District SBHC Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150617001352 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 1699154500. Details of each certification follow.

Federally qualified health center certification: CCN 231060

Legal name
HACKLEY COMMUNITY CARE CENTER INC
Doing business as
OAKRIDGE SCHOOL DISTRICT SBHC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 30, 2015
Last certification
Jun 30, 2015
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Enrollment address
251 S Wolf Lake Road
Muskegon, MI 49442-3029

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 Care34 organizations share this tax ID, including this one

Other organizations with this tax ID 33

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

View all 33

Locations

251 S Wolf Lake Rd
Muskegon, MI 49442
Phone (231) 788-7461

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
Javier Martinez Individual Corporate DirectorBoard Member Jan 24, 2012
Christopher Sandford Individual Corporate DirectorBoard Member Jan 24, 2012
Michael Weessies Individual Corporate OfficerCeo Jun 1, 2022
Harold Santo Individual Corporate DirectorBoard Member Jan 24, 2012
Sarah Rinesma Sybenga Individual Corporate DirectorBoard Member Jan 24, 2012
Valerie Jan Blondin Individual Corporate OfficerCfo Jan 24, 2012
W-2 Managing EmployeeCfo Jan 24, 2012 1%
Cheryl L Nebedum Individual Corporate DirectorBoard Member Jan 24, 2012
Stephanie Tanis Individual Corporate DirectorBoard Member Jan 24, 2012
Gary M Lukkari Individual Corporate DirectorBoard Member Jan 24, 2012
Jeffrey Alexander Individual Corporate DirectorBoard Member 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 3

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": "1448323200000",
    "number": "1699154500",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2700 BAKER ST",
            "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": "251 S WOLF LAKE RD",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494423029",
            "telephone_number": "231-788-7461"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HACKLEY COMMUNITY CARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-26",
        "last_updated": "2015-11-24",
        "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": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1699154500",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Oakridge School District SBHC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Muskegon, MI

Sources for this page

Verify at the official NPI Registry.