Provider Demographics
NPI:1164557237
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:COMMUNITY CARE OF GREEN BANK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO CFO
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-924-6262
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:ROCK CAVE
Mailing Address - State:WV
Mailing Address - Zip Code:26234
Mailing Address - Country:US
Mailing Address - Phone:304-924-6262
Mailing Address - Fax:904-924-5460
Practice Address - Street 1:90 ROUTE 28
Practice Address - Street 2:
Practice Address - City:GREEN BANK
Practice Address - State:WV
Practice Address - Zip Code:24944-0085
Practice Address - Country:US
Practice Address - Phone:304-456-5115
Practice Address - Fax:304-456-5117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010087Medicaid
WV3810010087Medicaid
WV511931Medicare Oscar/Certification