Provider Demographics
NPI:1619464369
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:COMMUNITY CARE OF WESTON II
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:304-561-5319
Mailing Address - Street 1:249 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:304-561-5319
Mailing Address - Fax:
Practice Address - Street 1:107 STAUNTON DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-5604
Practice Address - Country:US
Practice Address - Phone:304-269-2022
Practice Address - Fax:304-269-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)