Provider Demographics
NPI:1821349309
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:WEST MILFORD ELEMENTARY SCHOOL WELLNESS CENTER
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 1:226 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:WV
Mailing Address - Zip Code:26451-9700
Mailing Address - Country:US
Mailing Address - Phone:304-326-7030
Mailing Address - Fax:304-745-4488
Practice Address - Street 1:226 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:WEST MILFORD
Practice Address - State:WV
Practice Address - Zip Code:26451-9700
Practice Address - Country:US
Practice Address - Phone:304-326-7030
Practice Address - Fax:304-745-4488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-25
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2273-9509261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)