NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Lumberport Elementary School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Lumberport, WV
National Provider Identifier
1649610445
Registry record updated Jun 26, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
2287-3648 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Lumberport Elementary School Wellness Center
Practice address
Chestnut & Lyndon Streets
Lumberport, WV 26386-0000
Phone
(304) 326-7020
Fax
(304) 584-5943
NPI assigned
Jun 26, 2013
Last updated
Jun 26, 2013By 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 Jun 26, 2013

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

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 2287-3648 WV Primary

Addresses

Primary practice location

Chestnut & Lyndon Streets
Lumberport, WV 26386-0000

Mailing address

PO Box 217
Rock Cave, WV 26234-0217
Phone (304) 924-6262

Other identifiers 1

IdentifierTypeStateIssuer
2287-3648OtherWVBUSINESS LICENSE

Other names 1

  • Lumberport Elementary 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
O20131028001753 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Lumberport, WV
O20140407001269 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 19 practitioners
Practice locations: Lumberport, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649610445. Details of each certification follow.

Federally qualified health center certification: CCN 511034

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
LUMBERPORT ELEMENTARY SCHOOL WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 5, 2013
Last certification
Nov 5, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
Chestnut Lyndon STS
Lumberport, WV 26386

National Provider Directory

National Provider Directory
Part of
Primary Care Systems Inc

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 OfficerCmo Sep 1, 2003
Dora L. Potasnik Individual W-2 Managing EmployeeCredentialing Jan 9, 2012
Juston Chad Morrison Individual Corporate Director Apr 10, 2017
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 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 Director Jan 1, 2018
Selah Raines Individual Corporate Director Jan 1, 2020
David D Taylor Individual Corporate Director Mar 14, 2016
Katherine Anne Horner Individual Corporate DirectorBoard Vice- President Jan 14, 2019
Patricia Louise Collett Individual Corporate OfficerCoo Nov 18, 2000
Steven Roy Flaughers Individual Corporate Director 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 Director 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 83

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 83

NPI Registry JSON

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

{
    "created_epoch": "1372204800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1372204800000",
    "number": "1649610445",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 217",
            "city": "ROCK CAVE",
            "state": "WV",
            "postal_code": "262340217",
            "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": "CHESTNUT & LYNDON STREETS",
            "city": "LUMBERPORT",
            "state": "WV",
            "postal_code": "263860000",
            "telephone_number": "304-326-7020",
            "fax_number": "304-584-5943"
        }
    ],
    "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": "2013-06-26",
        "last_updated": "2013-06-26",
        "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": "WV",
            "license": "2287-3648",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BUSINESS LICENSE",
            "identifier": "2287-3648",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lumberport Elementary School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lumberport, WV

Sources for this page

Verify at the official NPI Registry.