Community Care of West Virginia, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Sutton, WV
NPI 1104175058 · NPPES record last updated Oct 2, 2012
Key facts
- NPI
- 1104175058
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- License
- 2274-1062 (WV)
- Legal business name
- COMMUNITY CARE OF WEST VIRGINIA, INC.
- Practice address
- 100 Carter Braxton Dr
Sutton, WV 26601-9773 - Phone
- (304) 765-2644
- Fax
- (304) 765-2696
- NPI assigned
- Sep 6, 2012
- Organization subpart
- Yes
- Parent organization (as reported)
- COMMUNITY CARE OF WEST VIRGINIA, INC.
Authorized official
- Name
- Richard G Simon
- Title
- Ceo
- Phone
- (304) 924-6262
Owners & managing parties with NPI records 2
-
Patricia L Collett, PA-C
Other NPIs on the same Medicare enrollment 1
Practitioners 88
-
Allyson Malone Andrews, PA-C
-
Nicholas Joel Baker, PA-C
-
Barbara Ballash, LICENSED PSYCHOLOGIS
-
Angela Gayle Carter, APRN, BC
-
Patricia L Collett, PA-C
-
Betsy Coulter, LICSW
-
Melany W Davis, LICSW
-
Ashley Renee Hart, FNP
-
Stephanie Hope Jackson, APRN, FNP-BC
-
Jason S. Kidd, PA-C
-
Erin Nicole King, FNP-BC
-
Genevieve F Larimer Dunn, FNP-BC
-
Christy L Lucas, PA-C
-
Holly A Osborne, PA-C
-
Megan Lynnette Parker, LGSW
-
Heather Anne Radcliffe, LICSW ACSW
-
Rachel Marie Taylor, PA-C
-
Joshua Steven Baker, PAC
-
Sarah Bell, DNP
-
Paula Blount, PA
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WV
Federally qualified health center certification: CCN 511009
- Legal name
- COMMUNITY CARE OF WEST VIRGINIA, INC.
- Doing business as
- BRAXTON COUNTY MIDDLE SCHOOL WELLNESS CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Nov 27, 2012
- Last certification
- Nov 27, 2012
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jul 1, 1984 in WV
- Enrollment address
- 100 Carter Braxton Dr
Sutton, WV 26601-9773
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Sarah Chouinard |
Corporate Officer |
Sep 1, 2003 | |
| Dora L. Potasnik |
W-2 Managing Employee | Jan 9, 2012 | |
| Karen E Grant |
Corporate Director | Apr 1, 2011 | |
| Juston Chad Morrison |
Corporate Director |
Apr 10, 2017 | |
| Elisabeth M Samples |
Corporate Director |
Jan 1, 2018 | |
| Michele Williams |
Corporate Officer |
Dec 12, 2005 | |
| Richard G Simon |
Corporate Director |
Sep 13, 1993 | |
| David B Malcomb |
Corporate Director |
Jan 1, 2018 | |
| Connie a Johnston |
Corporate Officer |
Mar 1, 2014 | |
| David D Taylor |
Corporate Director |
Mar 14, 2018 | |
| Renee a Hofer |
Corporate Director | Apr 1, 2011 | |
| Patricia Louise Collett |
Corporate Officer |
Nov 18, 2000 | |
| Gregory H Moore |
Corporate Director |
Oct 15, 2013 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| West Virginia Wesleyan College Wellness Center |
Federally qualified health center | Operational/Managerial Control (100%) | May 21, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130226000494 | WV | Part B Supplier - Clinic/Group Practice | 0446232987 |
Receives reassigned benefits from 19 practitioners 1 other NPI on this enrollment Practice locations: Buckhannon, WV; Sutton, WV |
| O20181029002309 | WV | Part a Provider - Federally Qualified Health Center (FQHC) | 0446232987 | Practice locations: Sutton, WV |
National Provider Directory
- Part of
- Leading Creek Elem
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | 2274-1062 | WV | Yes |
Addresses
Primary practice location
100 Carter Braxton Dr
Sutton, WV 26601-9773
Mailing address
100 Carter Braxton Dr
Sutton, WV 26601-9773
Phone (304) 765-2644
Other names
- Braxton County Middle School Wellness Center
Other providers in Sutton, WV
- Reva Marlana Cogar
- Ricki Ann Cogar
- Miranda Joyce Collins
- Sonja L Collins
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
All providers in Sutton, WV · Federally Qualified Health Center (FQHC) in West Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 2, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.