Basic Information
Provider Information | |||||||||
NPI: | 1992755789 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLAY COUNTY HIGH SCHOOL WELLNESS CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 147 | ||||||||
Address2: |   | ||||||||
City: | CLAY | ||||||||
State: | WV | ||||||||
PostalCode: | 250430147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045877301 | ||||||||
FaxNumber: | 3045872594 | ||||||||
Practice Location | |||||||||
Address1: | ONE PANTHER DRIVE | ||||||||
Address2: |   | ||||||||
City: | CLAY | ||||||||
State: | WV | ||||||||
PostalCode: | 250430729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045872867 | ||||||||
FaxNumber: | 3045872867 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 09/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTASNIK | ||||||||
AuthorizedOfficialFirstName: | DORA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 3043177275 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY CARE OF WEST VIRGINIA, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2267-4838 | WV | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 001979216 | 01 | WV | MS BCBS | OTHER | 0035189006 | 05 | WV |   | MEDICAID |