Provider Demographics
NPI:1861831323
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:LUMBERPORT MIDDLE SCHOOL WELLNESS CENTER
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:304-587-2541
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:ROCK CAVE
Mailing Address - State:WV
Mailing Address - Zip Code:26234-0217
Mailing Address - Country:US
Mailing Address - Phone:304-924-6262
Mailing Address - Fax:304-924-5460
Practice Address - Street 1:314 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUMBERPORT
Practice Address - State:WV
Practice Address - Zip Code:26386-8000
Practice Address - Country:US
Practice Address - Phone:304-326-7540
Practice Address - Fax:304-584-4602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2287-8807261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2287-8807OtherBUSINESS LICENSE