Provider Demographics
NPI:1609042266
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:COMMUNITY CARE CONNECTIONS OF FLATWOODS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
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 1:235 SKIDMORE LN
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:WV
Mailing Address - Zip Code:26601-9272
Mailing Address - Country:US
Mailing Address - Phone:304-765-4400
Mailing Address - Fax:304-765-0354
Practice Address - Street 1:235 SKIDMORE LN
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:WV
Practice Address - Zip Code:26601-9272
Practice Address - Country:US
Practice Address - Phone:304-765-4400
Practice Address - Fax:304-765-0354
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-05
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013073Medicaid
WV511939Medicare Oscar/Certification
WV5119391Medicare PIN