Provider Demographics
NPI:1427305911
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-924-6262
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:6404 POTOMAC HIGHLAND TRAIL
Mailing Address - City:GREEN BANK
Mailing Address - State:WV
Mailing Address - Zip Code:24944-0085
Mailing Address - Country:US
Mailing Address - Phone:304-456-5433
Mailing Address - Fax:304-456-5439
Practice Address - Street 1:6404 POTOMAC HIGHLAND TRAIL
Practice Address - Street 2:
Practice Address - City:GREEN BANK
Practice Address - State:WV
Practice Address - Zip Code:24944-6404
Practice Address - Country:US
Practice Address - Phone:304-456-5433
Practice Address - Fax:304-456-5439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental