Community Care of West Virginia, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Bridgeport, WV
NPI 1326434846 · NPPES record last updated Apr 10, 2015
Key facts
- NPI
- 1326434846
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- COMMUNITY CARE OF WEST VIRGINIA, INC.
- Practice address
- 515 Johnston Avenue
Bridgeport, WV 26330-1311 - Phone
- (304) 326-7137
- Fax
- (304) 587-2594
- NPI assigned
- Apr 10, 2015
- Organization subpart
- No
Authorized official
- Name
- Dora L Potasnik
- Title
- Credentialing
- Phone
- (304) 587-2541
Owners & managing parties with NPI records 3
-
Patricia L Collett, PA-C
Practitioners 9
-
Melissa S Dodrill, M.D.
-
Genevieve F Larimer Dunn, FNP-BC
-
Jaclyn K Swick, PA-C
-
Nicholas Joel Baker, PA-C
-
Christy L Lucas, PA-C
-
Rachel Marie Taylor, PA-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WV
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
- Corporation · Non-profit
- Incorporated
- Jul 1, 1984 in WV
- Enrollment address
- 515 Johnson Ave
Bridgeport, WV 26330-1311
All disclosed owners & managing parties 19
| Name | Role | Since | Share |
|---|---|---|---|
| Dora L. Potasnik |
W-2 Managing Employee |
Jan 9, 2012 | |
| Kristi Walkr |
Corporate Officer |
Oct 15, 2022 | |
| Juston Chad Morrison |
Corporate Director |
Jan 1, 2020 | |
| Elisabeth M Samples |
Corporate Director |
Jan 1, 2018 | |
| Michele Williams |
Corporate Officer |
Dec 12, 2005 | |
| Jeffrey Jenkins |
Corporate Officer |
Apr 4, 2022 | |
| David B Malcomb |
Corporate Director |
Jan 1, 2020 | |
| Selah Raines |
Corporate Director |
Jan 1, 2020 | |
| David D Taylor |
Corporate Director |
Mar 14, 2016 | |
| Abigail Friend |
W-2 Managing Employee |
Aug 1, 2023 | |
| Katherine Anne Horner |
Corporate Director |
Jan 14, 2019 | |
| Kimberly Renee Becher |
Corporate Officer |
Sep 23, 2021 | |
| Patricia Louise Collett |
Corporate Officer |
Jan 18, 2000 | 100% |
| Steven Roy Flaughers |
Corporate Director |
Jan 14, 2019 | |
| Shelly Gause |
W-2 Managing Employee |
Jan 28, 2023 | |
| Rosemary M Thomas |
Corporate Director |
Jan 1, 2020 | |
| James L Estep |
Corporate Director |
Jan 1, 2020 | |
| Sarina Smith |
Corporate Director |
Jan 14, 2019 | |
| Kevin Douglas Junkins |
Corporate Officer |
Jun 9, 2017 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| West Virginia Wesleyan College Wellness Center |
Federally qualified health center | Operational/Managerial Control (100%) | May 21, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150528000266 | WV | Part a Provider - Federally Qualified Health Center (FQHC) | 0446232987 | Practice locations: Bridgeport, WV |
| O20150911002474 | WV | Part B Supplier - Clinic/Group Practice | 0446232987 |
Receives reassigned benefits from 5 practitioners Practice locations: Bridgeport, WV |
National Provider Directory
Locations
515 Johnson Ave
Bridgeport, WV 26330
Phone (304) 326-7137
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
515 Johnston Avenue
Bridgeport, WV 26330-1311
Mailing address
PO Box 147
Clay, WV 25043-0147
Phone (304) 587-2541
Other names
- Bridgeport High School Wellness Center
Other providers in Bridgeport, WV
- Jeffery S Collins
- David Forrest Colvin
- Community Care of West Virginia
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
- Community Care of West Virginia, Inc.
All providers in Bridgeport, WV · Federally Qualified Health Center (FQHC) in West Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 10, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.