1164557237 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 1164557237 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:
1164557237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK CAVE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-924-6262
Provider Business Mailing Address Fax Number:
904-924-5460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 ROUTE 28
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BANK
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24944-0085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-456-5115
Provider Business Practice Location Address Fax Number:
304-456-5117
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIMMONS
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO CFO
Authorized Official Telephone Number:
304-924-6262

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , 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: 3810010087 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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