NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as South Harrison Middle School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Lost Creek, WV
National Provider Identifier
1699024547
Registry record updated Mar 21, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
2273-6225 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
South Harrison Middle School Wellness Center
Practice address
RR 1 Box 58B
Lost Creek, WV 26385-9707
Phone
(304) 326-7460
Fax
(304) 745-5587
NPI assigned
Sep 6, 2012
Last updated
Mar 21, 2019By 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 Mar 21, 2019

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) 561-5319

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 2273-6225 WV Primary

Addresses

Primary practice location

RR 1 Box 58B
Lost Creek, WV 26385-9707

Mailing address

RR 1 Box 58B
Lost Creek, WV 26385-9707
Phone (304) 326-7460

Other names 1

  • South Harrison Middle 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
O20130226000587 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 24 practitioners
Practice locations: Lost Creek, WV
O20190722003351 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Lost Creek, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699024547. Details of each certification follow.

Federally qualified health center certification: CCN 511010

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
SOUTH HARRISON MIDDLE 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
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
RR 1 Box 58B
Lost Creek, WV 26385-9707

National Provider Directory

National Provider Directory
Part of
Community Care of West Virginia

Ownership & related parties

All disclosed owners & managing parties 15

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 Jan 9, 2012
Karen E Grant Individual Corporate DirectorBoard Scretary Apr 1, 2011
Juston Chad Morrison Individual Corporate DirectorBoard Member Apr 10, 2017
Thomas G Lynch Individual Corporate DirectorBoard President Jul 1, 2007
Elisabeth M Samples Individual Corporate DirectorBoard Member Jan 1, 2018
Michele Williams Individual Corporate Officer 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 OfficerCfo Mar 1, 2014
David D Taylor Individual Corporate DirectorBoard Member Mar 14, 2016
Renee a Hofer Individual Corporate DirectorBoard VP Jul 1, 2007
Patricia Louise Collett Individual Corporate OfficerCoo Nov 18, 2000
Thelma J Samples Individual Corporate DirectorBoard Treasurer Apr 1, 2011
Gregory H Moore Individual Corporate DirectorBoard Member Oct 15, 2013

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 75

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 75

NPI Registry JSON

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

{
    "created_epoch": "1346889600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1553126400000",
    "number": "1699024547",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "RR 1 BOX 58B",
            "city": "LOST CREEK",
            "state": "WV",
            "postal_code": "263859707",
            "telephone_number": "304-326-7460",
            "fax_number": "304-745-5587"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "RR 1 BOX 58B",
            "city": "LOST CREEK",
            "state": "WV",
            "postal_code": "263859707",
            "telephone_number": "304-326-7460",
            "fax_number": "304-745-5587"
        }
    ],
    "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": "2012-09-06",
        "last_updated": "2019-03-21",
        "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": "304-561-5319"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WV",
            "license": "2273-6225",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Harrison Middle School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South Harrison Middle School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lost Creek, WV

Sources for this page

Verify at the official NPI Registry.