Basic Information
| Provider Information | |||||||||
| NPI: | 1619103041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BIG OTTER ELEMENTARY SCHOOL WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 217 | ||||||||
| Address2: | |||||||||
| City: | ROCK CAVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262340217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049246262 | ||||||||
| FaxNumber: | 3049245460 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 OSSIA RD | ||||||||
| Address2: | |||||||||
| City: | DUCK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250638500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042862838 | ||||||||
| FaxNumber: | 3045872464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTASNIK | ||||||||
| AuthorizedOfficialFirstName: | DORA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3043177275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2022 | ||||||||
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 | 3810017436 | 05 | WV | MEDICAID |