NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Green Bank Elementary-Middle School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Green Bank, WV
National Provider Identifier
1194073486
Registry record updated Aug 17, 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
Green Bank Elementary-Middle School Wellness Center
Practice address
RR 1 Box 5
Green Bank, WV 24944-9703
Phone
(304) 456-4865
Fax
(304) 456-5162
NPI assigned
Aug 17, 2012
Organization subpart
Yes
Parent organization
COMMUNITY CARE OF WEST VIRGINIA, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 17, 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 Primary

Addresses

Primary practice location

RR 1 Box 5
Green Bank, WV 24944-9703

Mailing address

RR 1 Box 5
Green Bank, WV 24944-9703
Phone (304) 456-4865

Other names 1

  • Green Bank Elementary-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
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…
O20121009000581 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Green Bank, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194073486. Details of each certification follow.

Federally qualified health center certification: CCN 511001

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
GREEN BANK ELEMENTARY-MIDDLE SCHOOL WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 15, 2012
Last certification
Oct 15, 2012
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
5917 Potomac Highlands TRL
Green Bank, WV 24944-9099

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
Primary Care Systems Inc

Locations

5917 Potomac Highlands Trl
Green Bank, WV 24944
Phone (304) 456-4348

Ownership & related parties

All disclosed owners & managing parties 17

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 OfficerChief Medical Officer Oct 15, 2012
Dora L. Potasnik Individual W-2 Managing EmployeeCredentialing Coordinator Jan 9, 2012
Juston Chad Morrison Individual Corporate DirectorBoard Member Jan 1, 2020
Hillary Nicole Tenney Individual W-2 Managing EmployeeCredentialing Coordinator Aug 1, 2019
Elisabeth M Samples Individual Corporate DirectorBoard Secretary Jan 1, 2018
Michele Williams Individual Corporate OfficerCompliance Officer Oct 15, 2012
Jeffrey Jenkins Individual Corporate OfficerCfo Apr 4, 2022
Richard G Simon Individual Corporate OfficerCeo Sep 13, 1993 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
Patricia Louise Collett Individual Corporate OfficerCoo Oct 15, 2012
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 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1345161600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1345161600000",
    "number": "1194073486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "RR 1 BOX 5",
            "city": "GREEN BANK",
            "state": "WV",
            "postal_code": "249449703",
            "telephone_number": "304-456-4865",
            "fax_number": "304-456-5162"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "RR 1 BOX 5",
            "city": "GREEN BANK",
            "state": "WV",
            "postal_code": "249449703",
            "telephone_number": "304-456-4865",
            "fax_number": "304-456-5162"
        }
    ],
    "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": "2012-08-17",
        "last_updated": "2012-08-17",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Green Bank Elementary-Middle School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Green Bank, WV

Sources for this page

Verify at the official NPI Registry.