Provider Demographics
NPI:1992754592
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
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 147
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-0147
Mailing Address - Country:US
Mailing Address - Phone:304-587-7301
Mailing Address - Fax:304-587-2464
Practice Address - Street 1:797 CLINIC DR
Practice Address - Street 2:
Practice Address - City:IVYDALE
Practice Address - State:WV
Practice Address - Zip Code:25113-8263
Practice Address - Country:US
Practice Address - Phone:304-286-4200
Practice Address - Fax:304-286-2107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV550630765002261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001898548OtherMS BCBS
WV0035398000Medicaid
WV5118641Medicare PIN
WV001898548OtherMS BCBS
WV511864Medicare Oscar/Certification