Provider Demographics
NPI:1558563734
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:COMMUNITY CARE OF WEST MILFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:L
Authorized Official - Last Name:POTASNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-317-7275
Mailing Address - Street 1:597 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:WV
Mailing Address - Zip Code:26451-6801
Mailing Address - Country:US
Mailing Address - Phone:304-745-4568
Mailing Address - Fax:304-326-3700
Practice Address - Street 1:597 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WEST MILFORD
Practice Address - State:WV
Practice Address - Zip Code:26451-6801
Practice Address - Country:US
Practice Address - Phone:304-745-4568
Practice Address - Fax:304-326-3700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-01
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1558563734Medicaid
WV511932Medicare Oscar/Certification
WV5119321Medicare PIN