Community Care of West Virginia, Inc.

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

COMMUNITY CARE OF WEST VIRGINIA, INC.

Doing business as

Bridgeport High School Wellness Center

Practice address

515 Johnston Avenue
Bridgeport, WV 26330-1311

Phone

(304) 326-7137

Fax

(304) 587-2594

NPI assigned

Apr 10, 2015

Last updated

Apr 10, 2015By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dora L Potasnik

Title

Credentialing

Phone

(304) 587-2541

Specialties & licenses 1

Addresses

Other names 1

• Bridgeport High School Wellness Center Doing business as

Medicare fee-for-service enrollment

Enrolled in WV2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1326434846. Details of each certification follow.

• CCN 511066 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN 511066

Legal name

COMMUNITY CARE OF WEST VIRGINIA, INC.

Doing business as

BRIDGEPORT HIGH SCHOOL WELLNESS CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Apr 22, 2015

Last certification

Apr 22, 2015

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Incorporated

Jul 1, 1984 in WV

Enrollment address

515 Johnson Ave
Bridgeport, WV 26330-1311

All disclosed owners & managing parties 19

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

Owners & managing parties with NPI records 3

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

• Kimberly R Becher, MD

  • Family Medicine Physician
  • Clay, WV
  • NPI 1528351863

  Corporate Officer

  CMS ownership
• Patricia L Collett, PA-C

  • Medical Physician Assistant
  • Rock Cave, WV
  • NPI 1528008760

  Corporate Officer

  CMS ownership
• Kevin Douglas Junkins, MD

  • Psychiatry Physician
  • Bridgeport, WV
  • NPI 1629344858

  Corporate Officer

  CMS ownership

All facility ownership & control disclosures 1

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

Practitioners 5

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.

• Melissa S Dodrill, M.D.

  • Family Medicine Physician
  • West Milford, WV
  • NPI 1871887349
  Medicare reassignment NPD
• Genevieve F Larimer Dunn, FNP-BC

  • Family Nurse Practitioner
  • Buckhannon, WV
  • NPI 1861708513
  Medicare reassignment NPD
• Jaclyn K Swick, PA-C

  • Physician Assistant
  • Weston, WV
  • NPI 1023332699
  Medicare reassignment NPD
• Iris Mae Canete Trinidad-Carillo, M.D

  • Family Medicine Physician
  • Rock Cave, WV
  • NPI 1386873024
  Medicare reassignment NPD
• Aimee M Whitehair, MD

  • Family Medicine Physician
  • Rock Cave, WV
  • NPI 1003093097
  Medicare reassignment NPD

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

{
    "created_epoch": "1428624000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1428624000000",
    "number": "1326434846",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 147",
            "city": "CLAY",
            "state": "WV",
            "postal_code": "250430147",
            "telephone_number": "304-587-2541",
            "fax_number": "304-587-2594"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "515 JOHNSTON AVENUE",
            "city": "BRIDGEPORT",
            "state": "WV",
            "postal_code": "263301311",
            "telephone_number": "304-326-7137",
            "fax_number": "304-587-2594"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY CARE OF WEST VIRGINIA, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-10",
        "last_updated": "2015-04-10",
        "status": "A",
        "authorized_official_last_name": "POTASNIK",
        "authorized_official_first_name": "DORA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "304-587-2541"
    },
    "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": "Bridgeport High School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jeffery S Collins, MA
• David Forrest Colvin, MD
• Community Care of West Virginia
• Community Care of West Virginia, Inc. (Community Care of Bridgeport)
• Community Care of West Virginia, Inc. (Community Care of Bridgeport)
• Community Care of West Virginia, Inc. (Community Care of Bridgeport)
• Community Care of West Virginia, Inc. (Community Care Pharmacy of Bridgeport)
• Community Care of West Virginia, Inc. (Bridgeport Middle School Wellness Center)
• Community Care of West Virginia, Inc. (Simpson Elementary School Wellness Center)
• Community Care of West Virginia, Inc. (Johnson Elementary School Wellness Center)

• Federally Qualified Health Center (FQHC) in Bridgeport, WV
• Providers in Bridgeport, WV by specialty
• Federally Qualified Health Center (FQHC) in West Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.