| Organization Name: | COMMUNITY CARE OF WEST VIRGINIA, INC. |
| NPI Number: | 1649610437 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DORA L POTASNIK (CREDENTIALING) |
| Mailing Address: | 200 Tetrick Rd Shinnston |
| State: | WV US |
| Postal Code: | 264319704 |
| Phone Number: | 3043267280 |
| Fax Number: | 3043267293 |
| NPI Enumeration Date: | 06/26/2013 |
| NPI Last Update Date: | 06/26/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | 2287-8118 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WV |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |