MEDICARE: COMMUNITY CARE OF WEST VIRGINIA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255507810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE OF WEST VIRGINIA, INC.

Provider Business Mailing Address
First Line	:	4 NORTHRIDGE DR STE 118
Second Line	:
City	:	BUCKHANNON
State	:	WV
Zip	:	26201-8484
Country	:	US
Telephone Number	:	304-473-5660
Fax Number	:	304-473-5661

Provider Business Practice Location Address
First Line	:	4 NORTHRIDGE DR STE 118
Second Line	:
City	:	BUCKHANNON
State	:	WV
Zip	:	26201-8484
Country	:	US
Telephone Number	:	304-473-5660
Fax Number	:	304-473-5661

Authorized Official
Title or Position	:	CEO
Name	:	RICHARD G SIMON
Credential	:
Telephone Number	:	304-545-0571

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	01/19/2024

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