Provider Demographics
NPI:1619052750
Name:POTOMAC COMPREHENSIVE DIAGNOSTIC AND GUIDANCE CENTER INC
Entity Type:Organization
Organization Name:POTOMAC COMPREHENSIVE DIAGNOSTIC AND GUIDANCE CENTER INC
Other - Org Name:POTOMAC CENTER INC WASHINGTON ST GROUP NAME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PLOWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-822-3861
Mailing Address - Street 1:ONE BLUE STREET
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757
Mailing Address - Country:US
Mailing Address - Phone:304-822-3861
Mailing Address - Fax:304-822-4297
Practice Address - Street 1:ONE BLUE STREET
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757
Practice Address - Country:US
Practice Address - Phone:304-822-3861
Practice Address - Fax:304-822-4297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWVDHHR30315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003198000Medicaid