1790033082 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 1790033082 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:
MARLINTON ELEMENTARY SCHOOL WELLNESS CENTER
Provider Other Organization Name Type Code:
3
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:
1790033082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926A 5TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLINTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24954-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-799-6551
Provider Business Mailing Address Fax Number:
304-799-6552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
926A 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARLINTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24954-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-799-6551
Provider Business Practice Location Address Fax Number:
304-799-6552
Provider Enumeration Date:
08/17/2012

Additional Information

Authorized Official

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

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)





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