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NPI Code Detail

MEDICARE: COMMUNITY CARE OF WEST VIRGINIA, INC.

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
1261QF0400XFederally Qualified Health Center (FQHC)

General Provider Information

NPI Number : 1619348844
Entity Type Code : Organization
Provider Name (Legal Business Name) : COMMUNITY CARE OF WEST VIRGINIA, INC.
Provider Business Mailing Address
First Line : PO BOX 217
Second Line :
City : ROCK CAVE
State : WV
Zip : 26234-0217
Country : US
Telephone Number : 304-924-6262
Fax Number : 304-924-5460
Provider Business Practice Location Address
First Line : 65 PROFESSIONAL PL STE 102103
Second Line :
City : BRIDGEPORT
State : WV
Zip : 26330-0258
Country : US
Telephone Number : 304-848-5770
Fax Number : 304-848-0890
Authorized Official
Title or Position : CREDENTIALING
Name : DORA L POTASNIK
Credential :
Telephone Number : 304-587-2541
Provider Enumeration Date : 10/14/2015
Last Update Date : 02/20/2019

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Directions to “COMMUNITY CARE OF WEST VIRGINIA, INC. ” Practice Location

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