1992754592 NPI number — COMMUNITY CARE OF WEST VIRGINIA, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992754592 NPI number — COMMUNITY CARE OF WEST VIRGINIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE OF WEST VIRGINIA, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992754592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25043-0147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-587-7301
Provider Business Mailing Address Fax Number:
304-587-2464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
797 CLINIC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IVYDALE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25113-8263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-286-4200
Provider Business Practice Location Address Fax Number:
304-286-2107
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  550630765002 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001898548 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0035398000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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