Provider Demographics
NPI:1740310663
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:L
Authorized Official - Last Name:POTASNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-924-6262
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 1:100 S. PICKENS RD
Practice Address - Street 2:
Practice Address - City:HELVETIA
Practice Address - State:WV
Practice Address - Zip Code:26224-0027
Practice Address - Country:US
Practice Address - Phone:304-924-6262
Practice Address - Fax:304-924-5460
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035420000Medicaid
5118681Medicare PIN
WV0035420000Medicaid