1992755789 NPI number — COMMUNITY CARE OF WEST VIRGINIA, INC.

Table of content: (NPI 1992755789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992755789 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:
1992755789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2020
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:
304-587-2594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE PANTHER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25043-0729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-587-2867
Provider Business Practice Location Address Fax Number:
304-587-2867
Provider Enumeration Date:
05/11/2006

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 COORDINATOR
Authorized Official Telephone Number:
304-317-7275

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  2267-4838 , 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: 001979216 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0035189006 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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