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	:	1689921082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE OF WEST VIRGINIA, INC.

Provider Business Mailing Address
First Line	:	RR 2 BOX 305
Second Line	:
City	:	FRENCH CREEK
State	:	WV
Zip	:	26218-9667
Country	:	US
Telephone Number	:	304-924-6381
Fax Number	:	304-924-5460

Provider Business Practice Location Address
First Line	:	RR 2 BOX 305
Second Line	:
City	:	FRENCH CREEK
State	:	WV
Zip	:	26218-9667
Country	:	US
Telephone Number	:	304-924-6381
Fax Number	:	304-924-5460

Authorized Official
Title or Position	:	CEO
Name	:	RICHARD G SIMON
Credential	:
Telephone Number	:	304-924-6262

Provider Enumeration Date	:	08/06/2012
Last Update Date	:	08/06/2012

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