NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Braxton County High School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Sutton, WV
National Provider Identifier
1396096863
Registry record updated Oct 2, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
2273-6224 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Braxton County High School Wellness Center
Practice address
200 Jerry Burton Dr
Sutton, WV 26601-9768
Phone
(304) 765-7331
Fax
(304) 765-7976
NPI assigned
Sep 25, 2012
Last updated
Oct 2, 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 Oct 2, 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 2273-6224 WV Primary

Addresses

Primary practice location

200 Jerry Burton Dr
Sutton, WV 26601-9768

Mailing address

200 Jerry Burton Dr
Sutton, WV 26601-9768
Phone (304) 765-7331

Other names 1

  • Braxton County High 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
O20130226000634 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 27 practitioners
Practice locations: Sutton, WV
O20191118002541 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Sutton, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396096863. Details of each certification follow.

Federally qualified health center certification: CCN 511008

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
BRAXTON COUNTY HIGH SCHOOL WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 27, 2012
Last certification
Nov 27, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationProprietary
Incorporated
Jul 1, 1984 in WV
Enrollment address
200 Jerry Burton Dr
Sutton, WV 26601-9768

National Provider Directory

National Provider Directory
Tax ID family
Big Otter Elementary School Wellness Center7 organizations share this tax ID, including this one
Part of
Primary Care Systems Inc

Other organizations with this tax ID 6

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

Locations

200 Jerry Burton Dr
Sutton, WV 26601
Phone (304) 765-7331

Ownership & related parties

All disclosed owners & managing parties 16

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 Officer Sep 1, 2003
Dora L. Potasnik Individual W-2 Managing Employee Jul 30, 2019
Juston Chad Morrison Individual Corporate DirectorBoard Member Apr 10, 2017
Thomas G Lynch Individual Corporate Director Jul 1, 2007
Elisabeth M Samples Individual Corporate DirectorBoard Member Jan 1, 2018
Michele Williams Individual Corporate OfficerCompliance Office Dec 12, 2005
Richard G Simon Individual Corporate OfficerCeo Sep 13, 1993 100%
David B Malcomb Individual Corporate DirectorBoard Member Jan 1, 2018
Connie a Johnston Individual Corporate Officer Mar 1, 2014
David D Taylor Individual Corporate DirectorBoard Member Mar 14, 2016
Katherine Anne Horner Individual Corporate Director Jan 14, 2019
Patricia Louise Collett Individual Corporate Officer Nov 18, 2000
Steven Roy Flaughers Individual Corporate DirectorBoard Member Jan 14, 2019
Thelma J Samples Individual Corporate DirectorBoard Memebr Apr 1, 2011
Gregory H Moore Individual Corporate DirectorBoard Member Oct 15, 2013
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 84

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 84

NPI Registry JSON

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

{
    "created_epoch": "1348531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1349136000000",
    "number": "1396096863",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 JERRY BURTON DR",
            "city": "SUTTON",
            "state": "WV",
            "postal_code": "266019768",
            "telephone_number": "304-765-7331",
            "fax_number": "304-765-7976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 JERRY BURTON DR",
            "city": "SUTTON",
            "state": "WV",
            "postal_code": "266019768",
            "telephone_number": "304-765-7331",
            "fax_number": "304-765-7976"
        }
    ],
    "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": "2012-09-25",
        "last_updated": "2012-10-02",
        "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": "WV",
            "license": "2273-6224",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Braxton County High School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sutton, WV

Sources for this page

Verify at the official NPI Registry.