Provider Demographics
NPI:1598319915
Name:HACKLEY COMMUNITY CARE CENTER INC
Entity Type:Organization
Organization Name:HACKLEY COMMUNITY CARE CENTER INC
Other - Org Name:BUNKER ELEMENTARY SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-737-1335
Mailing Address - Street 1:2700 BAKER ST
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:231-737-1335
Mailing Address - Fax:
Practice Address - Street 1:2312 DENMARK ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1479
Practice Address - Country:US
Practice Address - Phone:231-733-6760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629066238Medicaid