Organization
HACKLEY COMMUNITY CARE CENTER INC
Active
Other names
Edgewood Elementary
Organization subpart
No
Provider details
NPI number
Authorized official
DANIELLE KOESTNER DO (CMO)
(231) 737-1335
Entity
Organization
Contact information
Practice address
3255 PONTALUNA RD, FRUITPORT, MI 49415-9600
(231) 733-6720
Mailing address
2700 BAKER ST FL 3, MUSKEGON, MI 49444-2157
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1629066238
—
MI
Enumeration date
07/26/2019
Last updated
07/26/2019
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