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General NPI Number Information
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NPI Number | 1992754592
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Entity Type | Organization
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Legal Business Name | COMMUNITY CARE OF WEST VIRGINIA, INC.
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Dates
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Enumeration Date | 05/09/2006
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Last Update Date | 01/19/2024
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Provider Practice Location Address
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Address Line | 797 CLINIC DR
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City | IVYDALE
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State | WV
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Zip | 25113-8263
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Country | US
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Telephone | 304-286-4200
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Fax | 304-286-2107
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Provider Business Mailing Address
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Address Line | PO BOX 147
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City | CLAY
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State | WV
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Zip | 25043-0147
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Country | US
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Telephone | 304-587-7301
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Fax | 304-587-2464
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Authorized Official
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Title or Position | CREDENTIALING
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Name | DORA L POTASNIK
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Credential |
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Telephone | 304-587-2541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number | 550630765002
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License Number State | WV
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