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)

General Provider Information

NPI Number	:	1104292168
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	:	1176 OIL CREEK RD
Second Line	:
City	:	ROANOKE
State	:	WV
Zip	:	26447-8263
Country	:	US
Telephone Number	:	304-452-0001
Fax Number	:	304-452-0002

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	DORA L POTASNIK
Credential	:
Telephone Number	:	304-587-2541

Provider Enumeration Date	:	08/13/2015
Last Update Date	:	08/25/2015

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