Basic Information
| Provider Information | |||||||||
| NPI: | 1194111468 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIBERTY HIGH 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: | 3045872541 | ||||||||
| FaxNumber: | 3045872594 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MOUNTAINEER DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263015511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043267470 | ||||||||
| FaxNumber: | 3045872594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | POTASNIK | ||||||||
| AuthorizedOfficialFirstName: | DORA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3045872541 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.