NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Sutton Elementary School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Sutton, WV
National Provider Identifier
1750892188
Registry record updated Oct 12, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Sutton Elementary School Wellness Center
Practice address
288 N Hill Rd
Sutton, WV 26601-1225
Phone
(304) 924-6262
Fax
(304) 924-5460
NPI assigned
Oct 12, 2017
Last updated
Oct 12, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2017

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) 587-2541

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

288 N Hill Rd
Sutton, WV 26601-1225

Mailing address

288 N Hill Rd
Sutton, WV 26601-1225
Phone (304) 924-6262

Other names 1

  • Sutton 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
O20180111002647 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Sutton, WV
O20180423000929 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 6 practitioners
Practice locations: Sutton, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1750892188. Details of each certification follow.

Federally qualified health center certification: CCN 511137

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
SUTTON ELEMENTARY SCHOOL WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 29, 2017
Last certification
Nov 29, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
288 N Hill Rd
Sutton, WV 26601-1225

National Provider Directory

National Provider Directory
Tax ID family
Community Care of West Virginia19 organizations share this tax ID, including this one

Other organizations with this tax ID 18

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

View all 18

Ownership & related parties

All disclosed owners & managing parties 14

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 OfficerMedical Director Sep 2, 2003
Dora L. Potasnik Individual W-2 Managing EmployeeCredentiaing Coordinator Jan 9, 2012
Karen E Grant Individual Corporate DirectorBoard Secretary Apr 1, 2011
Thomas G Lynch Individual Corporate DirectorBoard President Jul 1, 2007
Michele Williams Individual Corporate DirectorCompliance Officer Dec 12, 2005
Richard G Simon Individual Corporate OfficerCeo Sep 13, 1992 100%
Connie a Johnston Individual Corporate DirectorCfo Mar 1, 2014
David D Taylor Individual Corporate DirectorBoard Member Mar 14, 2016
Renee a Hofer Individual Corporate DirectorBoard Member Jul 1, 2007
Brock M Malcolm Individual Corporate OfficerCoo Aug 1, 2007
Patricia Louise Collett Individual Corporate DirectorDirector of Medical Services Nov 18, 2000
Thelma J Samples Individual Corporate DirectorBoard Member Apr 1, 2011
Gregory H Moore Individual Corporate DirectorBoard Member Oct 15, 2013
Travis M Miller Individual Corporate DirectorBoard Member Jul 1, 2007

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 114

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 114

NPI Registry JSON

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

{
    "created_epoch": "1507766400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1507766400000",
    "number": "1750892188",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "288 N HILL RD",
            "city": "SUTTON",
            "state": "WV",
            "postal_code": "266011225",
            "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": "288 N HILL RD",
            "city": "SUTTON",
            "state": "WV",
            "postal_code": "266011225",
            "telephone_number": "304-924-6262",
            "fax_number": "304-924-5460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY CARE OF WEST VIRGINIA, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-10-12",
        "last_updated": "2017-10-12",
        "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": "304-587-2541"
    },
    "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": "Sutton Elementary School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sutton, WV

Sources for this page

Verify at the official NPI Registry.