1619103041 NPI number — COMMUNITY CARE OF WEST VIRGINIA, INC.

Table of content: (NPI 1619103041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619103041 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:
1619103041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2022
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:
26234-0217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-924-6262
Provider Business Mailing Address Fax Number:
304-924-5460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
59 OSSIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUCK
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25063-8500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-286-2838
Provider Business Practice Location Address Fax Number:
304-587-2464
Provider Enumeration Date:
05/29/2009

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 COORDINATOR
Authorized Official Telephone Number:
304-317-7275

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810017436 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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