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	:	1215887054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE OF WEST VIRGINIA INC

Provider Business Mailing Address
First Line	:	1021 3RD ST
Second Line	:
City	:	NEW MARTINSVILLE
State	:	WV
Zip	:	26155-1554
Country	:	US
Telephone Number	:	304-473-5600
Fax Number	:	304-472-1341

Provider Business Practice Location Address
First Line	:	1021 3RD ST
Second Line	:
City	:	NEW MARTINSVILLE
State	:	WV
Zip	:	26155-1554
Country	:	US
Telephone Number	:	304-473-5600
Fax Number	:	304-472-1341

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	DORA L POTASNIK
Credential	:
Telephone Number	:	304-317-7275

Provider Enumeration Date	:	01/31/2026
Last Update Date	:	02/16/2026

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