Basic Information
| Provider Information | |||||||||
| NPI: | 1114277050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CAREXPRESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 77 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUCKHANNON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262012236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044735600 | ||||||||
| FaxNumber: | 3044721341 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUCKHANNON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262012236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044735600 | ||||||||
| FaxNumber: | 3044721341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2012 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIMON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3049246262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2274-1060 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2198-9937 | 01 | WV | WV BUSINESS REGISTRATION CERTIFICATE | OTHER |