NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Community Care of Green Bank

  • Federally Qualified Health Center (FQHC)
  • Green Bank, WV
National Provider Identifier
1164557237
Registry record updated Jan 25, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Community Care of Green Bank
Practice address
90 Route 28
Green Bank, WV 24944-0085
Phone
(304) 456-5115
Fax
(304) 456-5117
NPI assigned
Feb 22, 2007
Last updated
Jan 25, 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 Jan 25, 2012

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

Authorized official

Name
Connie Simmons
Title
Coo Cfo
Phone
(304) 924-6262

Specialties & licenses 1

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

Addresses

Primary practice location

90 Route 28
Green Bank, WV 24944-0085

Mailing address

PO Box 217
Rock Cave, WV 26234
Phone (304) 924-6262

Other identifiers 1

IdentifierTypeStateIssuer
3810010087MedicaidWV

Other names 1

  • Community Care of Green Bank Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20071018000710 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Green Bank, WV
O20071024000166 WV Part B Supplier - Public Health/Welfare Agency 0446232987 Receives reassigned benefits from 74 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clay, WV; Buckhannon, WV; West Milford, WV; Rock Cave, WV; Marlinton, WV; Ivydale, WV; Helvetia, WV; Green Bank, WV…

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1164557237. Details of each certification follow.

Federally qualified health center certification: CCN 511931

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
COMMUNITY CARE OF GREEN BANK
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 24, 2007
Last certification
Oct 24, 2007
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
4498 Potomac Highlands TRL
Green Bank, WV 24944

Other NPIs on the same Medicare enrollment 14

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

View all 14

National Provider Directory

National Provider Directory
Part of
Community Care of West Virginia

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Dora L. Potasnik Individual W-2 Managing EmployeeCredentialing Coordinator Sep 26, 2011
Kristi Walkr Individual Corporate OfficerCoo Oct 15, 2022
Juston Chad Morrison Individual Corporate DirectorBoard Member Jan 1, 2020
Hillary Nicole Tenney Individual W-2 Managing EmployeeCredentialing Coordinator Aug 1, 2018
Elisabeth M Samples Individual Corporate DirectorBoard Secretary Jan 1, 2018
Michele Williams Individual Corporate OfficerCompliance Officer Dec 12, 2005
Jeffrey Jenkins Individual Corporate OfficerCfo Apr 4, 2022
Richard G Simon Individual Corporate OfficerCeo Jul 1, 2007 100%
David B Malcomb Individual Corporate DirectorBoard Member Jan 1, 2020
Selah Raines Individual Corporate DirectorBoard Member Jan 1, 2020
David D Taylor Individual Corporate DirectorBoard Member Mar 14, 2016
Katherine Anne Horner Individual Corporate DirectorBoard Vice-President Jan 14, 2019
Kimberly Renee Becher Individual Corporate OfficerChief Medical Officer Sep 23, 2021
Patricia Louise Collett Individual Corporate OfficerDeputy Ceo Jan 18, 2000
Steven Roy Flaughers Individual Corporate DirectorBoard Member Jan 14, 2019
Rosemary M Thomas Individual Corporate DirectorBoard President Jan 1, 2020
James L Estep Individual Corporate DirectorBoard Treasurer Jan 1, 2020
Sarina Smith Individual Corporate DirectorBoard Member Jan 14, 2019

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 104

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 104

NPI Registry JSON

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

{
    "created_epoch": "1172102400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1327449600000",
    "number": "1164557237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 217",
            "city": "ROCK CAVE",
            "state": "WV",
            "postal_code": "26234",
            "telephone_number": "304-924-6262",
            "fax_number": "904-924-5460"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 ROUTE 28",
            "city": "GREEN BANK",
            "state": "WV",
            "postal_code": "249440085",
            "telephone_number": "304-456-5115",
            "fax_number": "304-456-5117"
        }
    ],
    "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": "2007-02-22",
        "last_updated": "2012-01-25",
        "status": "A",
        "authorized_official_last_name": "SIMMONS",
        "authorized_official_first_name": "CONNIE",
        "authorized_official_title_or_position": "COO CFO",
        "authorized_official_telephone_number": "304-924-6262"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WV",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3810010087",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Care of Green Bank",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Green Bank, WV

Sources for this page

Verify at the official NPI Registry.