NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Braxton County Middle School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Sutton, WV
National Provider Identifier
1104175058
Registry record updated Oct 2, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
2274-1062 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Braxton County Middle School Wellness Center
Practice address
100 Carter Braxton Dr
Sutton, WV 26601-9773
Phone
(304) 765-2644
Fax
(304) 765-2696
NPI assigned
Sep 6, 2012
Last updated
Oct 2, 2012By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY CARE OF WEST VIRGINIA, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 2, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Richard G Simon
Title
Ceo
Phone
(304) 924-6262

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 2274-1062 WV Primary

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 1

  • Braxton County Middle School Wellness Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104175058. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
100 Carter Braxton Dr
Sutton, WV 26601-9773

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Community Care of West Virginia

Locations

100 Carter Braxton Dr
Sutton, WV 26601
Phone (304) 765-2644

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Sarah Chouinard Individual Corporate OfficerMed Dir Sep 1, 2003
Dora L. Potasnik Individual W-2 Managing Employee Jan 9, 2012
Karen E Grant Individual Corporate Director Apr 1, 2011
Juston Chad Morrison Individual Corporate DirectorBoard Member Apr 10, 2017
Elisabeth M Samples Individual Corporate DirectorBoard Member Jan 1, 2018
Michele Williams Individual Corporate OfficerCompliance Offic Dec 12, 2005
Richard G Simon Individual Corporate DirectorCeo Sep 13, 1993
David B Malcomb Individual Corporate DirectorBoard Member Jan 1, 2018
Connie a Johnston Individual Corporate OfficerCfo Mar 1, 2014
David D Taylor Individual Corporate DirectorBoard Member Mar 14, 2018
Renee a Hofer Individual Corporate Director Apr 1, 2011
Patricia Louise Collett Individual Corporate OfficerCoo Nov 18, 2000
Gregory H Moore Individual Corporate DirectorBoard Member Oct 15, 2013

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
West Virginia Wesleyan College Wellness CenterBuckhannon, WV, CCN 511146 Federally qualified health center Operational/Managerial Control (100%) May 21, 2018

Practitioners & affiliated clinicians

Practitioners 88

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 88

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1346889600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1349136000000",
    "number": "1104175058",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CARTER BRAXTON DR",
            "city": "SUTTON",
            "state": "WV",
            "postal_code": "266019773",
            "telephone_number": "304-765-2644",
            "fax_number": "304-765-2696"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 CARTER BRAXTON DR",
            "city": "SUTTON",
            "state": "WV",
            "postal_code": "266019773",
            "telephone_number": "304-765-2644",
            "fax_number": "304-765-2696"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY CARE OF WEST VIRGINIA, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY CARE OF WEST VIRGINIA, INC.",
        "enumeration_date": "2012-09-06",
        "last_updated": "2012-10-02",
        "status": "A",
        "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"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WV",
            "license": "2274-1062",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Braxton County Middle School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sutton, WV

Sources for this page

Verify at the official NPI Registry.