Basic Information
| Provider Information | |||||||||
| NPI: | 1235877267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 GRACELAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | ELKINS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26241 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 70 GRACELAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | ELKINS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044735600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2022 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TENNEY | ||||||||
| AuthorizedOfficialFirstName: | HILLARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORTINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3043177425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2427-1445 | 01 | WV | BUSINESS LICENSE | OTHER |