NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Upshur County PALS Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Buckhannon, WV
National Provider Identifier
1194339309
Registry record updated Sep 4, 2020
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
Upshur County PALS Wellness Center
Practice address
33 E Victoria St
Buckhannon, WV 26201-2671
Phone
(304) 924-6262
Fax
(304) 924-5460
NPI assigned
Sep 4, 2020
Last updated
Sep 4, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 4, 2020

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

Authorized official

Name
Dora L Potasnik
Title
Credentialing Coordinator
Phone
(304) 317-7275

Specialties & licenses 1

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

Addresses

Primary practice location

33 E Victoria St
Buckhannon, WV 26201-2671

Mailing address

33 E Victoria St
Buckhannon, WV 26201-2671
Phone (304) 924-6262

Other names 1

  • Upshur County PALS 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
O20200921003189 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Buckhannon, WV
O20210107001153 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 2 practitioners
Practice locations: Buckhannon, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194339309. Details of each certification follow.

Federally qualified health center certification: CCN 511190

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
UPSHUR COUNTY PALS WELLNESS CENTER
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
33 E Victoria St
Buckhannon, WV 26201-2671

National Provider Directory

National Provider Directory
Tax ID family
Community Care of West Virginia19 organizations share this tax ID, including this one

Other organizations with this tax ID 18

Organizations that report the same tax identification number in the National Provider Directory.

View all 18

Locations

33 E Victoria St
Buckhannon, WV 26201
Phone (304) 473-2230

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 Jan 9, 2012
Kristi Walkr Individual Corporate OfficerCoo Oct 15, 2022
Juston Chad Morrison Individual Corporate DirectorBoard Member Apr 10, 2017
Hillary Nicole Tenney Individual W-2 Managing EmployeeCredentialing Coordinator Aug 1, 2019
Elisabeth M Samples Individual Corporate DirectorBoard Member 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 Sep 13, 1993 100%
David B Malcomb Individual Corporate DirectorBoard Member Jan 1, 2018
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 Member Jan 14, 2019
Kimberly Renee Becher Individual Corporate OfficerChief Medical Officer Sep 23, 2021
Patricia Louise Collett Individual Corporate OfficerDeputy Ceo Nov 18, 2000
Steven Roy Flaughers Individual Corporate DirectorBoard Member Jan 14, 2019
Rosemary M Thomas Individual Corporate DirectorBoard Member Jan 1, 2020
James L Estep Individual Corporate DirectorBoard Member 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 112

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 112

NPI Registry JSON

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

{
    "created_epoch": "1599177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599177600000",
    "number": "1194339309",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "33 E VICTORIA ST",
            "city": "BUCKHANNON",
            "state": "WV",
            "postal_code": "262012671",
            "telephone_number": "304-924-6262",
            "fax_number": "304-924-5460"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "33 E VICTORIA ST",
            "city": "BUCKHANNON",
            "state": "WV",
            "postal_code": "262012671",
            "telephone_number": "304-924-6262",
            "fax_number": "304-924-5460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY CARE OF WEST VIRGINIA, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-04",
        "last_updated": "2020-09-04",
        "certification_date": "2020-09-01",
        "status": "A",
        "authorized_official_last_name": "POTASNIK",
        "authorized_official_first_name": "DORA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "304-317-7275"
    },
    "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": "Upshur County PALS Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Buckhannon, WV

Sources for this page

Verify at the official NPI Registry.