Basic Information
| Provider Information | |||||||||
| NPI: | 1093765869 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLAY COUNTY MIDDLE SCHOOL WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147 | ||||||||
| Address2: | |||||||||
| City: | CLAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250430147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045877301 | ||||||||
| FaxNumber: | 3045872594 | ||||||||
| Practice Location | |||||||||
| Address1: | 236 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | CLAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250439412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045874375 | ||||||||
| FaxNumber: | 3045874375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | POTASNIK | ||||||||
| AuthorizedOfficialFirstName: | DORA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3045872541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2267-0579 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0035189005 | 05 | WV | MEDICAID | 001979216 | 01 | WV | MS BCBS | OTHER |