Organization
COMMUNITY CARE OF WEST VIRGINIA, INC.
Active
Parent organization
COMMUNITY CARE OF WEST VIRGINIA, INC.
Other names
Community Care of Big Otter
Organization subpart
Yes
Provider details
NPI number
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Authorized official
DORA L POTASNIK (CREDENTIALING)
(304) 587-2541
Entity
Organization
Contact information
Practice address
797 CLINIC DR, IVYDALE, WV 25113-8263
(304) 286-4200
(304) 286-2107
Mailing address
PO BOX 147, CLAY, WV 25043-0147
(304) 587-7301
(304) 587-2464
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
550630765002
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001898548
MS BCBS
WV
05
—
0035398000
—
WV
Enumeration date
05/09/2006
Last updated
01/19/2024
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