Provider Demographics
NPI:1235877267
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORTINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-317-7425
Mailing Address - Street 1:70 GRACELAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 GRACELAND DRIVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-473-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2427-1445OtherBUSINESS LICENSE