Basic Information
Provider Information | |||||||||
NPI: | 1699154591 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HACKLEY COMMUNITY CARE CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MUSKEGON HEIGHTS PUBLIC SCHOOL ACADEMY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2700 BAKER ST FL 3 | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494442157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317371335 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2441 SANFORD ST | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494441438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317336709 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2015 | ||||||||
LastUpdateDate: | 06/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOHN | ||||||||
AuthorizedOfficialFirstName: | WAYNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CMO | ||||||||
AuthorizedOfficialTelephone: | 2317371335 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1699154591 | 01 | MI | NPI | OTHER |