Provider Demographics
NPI:1922613975
Name:HACKLEY COMMUNITY CARE CENTER INC
Entity Type:Organization
Organization Name:HACKLEY COMMUNITY CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:WEGLARZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-733-6610
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:231-737-1335
Mailing Address - Fax:
Practice Address - Street 1:6245 SYERS RD STE A
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:MI
Practice Address - Zip Code:49425-7557
Practice Address - Country:US
Practice Address - Phone:231-733-6923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
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