Provider Demographics
NPI:1073021754
Name:HACKLEY COMMUNITY CARE CENTER INC
Entity Type:Organization
Organization Name:HACKLEY COMMUNITY CARE CENTER INC
Other - Org Name:OAKRIDGE LOWER ELEMENTARY SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JO ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPROCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-733-6804
Mailing Address - Street 1:2700 BAKER ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 N PARK ST STE A
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-1722
Practice Address - Country:US
Practice Address - Phone:231-788-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HACKLEY COMMUNITY CARE CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-17
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629066238Medicaid