Healthcare Provider Details

I. General information

NPI: 1063048189
Provider Name (Legal Business Name): COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 N KANAWHA ST
BUCKHANNON WV
26201-2714
US

IV. Provider business mailing address

34 N KANAWHA ST
BUCKHANNON WV
26201-2714
US

V. Phone/Fax

Practice location:
  • Phone: 304-924-6262
  • Fax: 304-924-6699
Mailing address:
  • Phone: 304-924-6262
  • Fax: 304-924-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DORA L POTASNIK
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 304-561-5319