Healthcare Provider Details

I. General information

NPI: 1710539630
Provider Name (Legal Business Name): COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5078 TALLMANSVILLE RD
BUCKHANNON WV
26201-1687
US

IV. Provider business mailing address

5078 TALLMANSVILLE RD
BUCKHANNON WV
26201-1687
US

V. Phone/Fax

Practice location:
  • Phone: 304-924-6262
  • Fax: 304-924-5460
Mailing address:
  • Phone: 304-924-6262
  • Fax: 304-924-5460

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