Community Care of West Virginia, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Buckhannon, WV
NPI 1811366248 · NPPES record last updated Sep 6, 2024
Key facts
- NPI
- 1811366248
- 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
- 167 Gawthrop Rd
Buckhannon, WV 26201-3927 - Phone
- (304) 473-5690
- Fax
- (304) 473-5692
- NPI assigned
- Sep 16, 2015
- Organization subpart
- No
Authorized official
- Name
- Dora L Potasnik
- Title
- Credentialing
- Phone
- (304) 317-7275
Owners & managing parties with NPI records 3
-
Patricia L Collett, PA-C
Other NPIs on the same Medicare enrollment 1
Practitioners 5
-
Barbara Ballash, LICENSED PSYCHOLOGIS
-
Ashley Renee Hart, FNP
-
Erin Nicole King, FNP-BC
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WV
Federally qualified health center certification: CCN 511075
- Legal name
- COMMUNITY CARE OF WEST VIRGINIA, INC.
- Doing business as
- HE WHITE ELEMENTARY SCHOOL WELLNESS CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 16, 2015
- Last certification
- Sep 16, 2015
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jul 1, 1984 in WV
- Enrollment address
- 501 Bomont Rd
Bomont, WV 25030-9666
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 |
|---|---|---|---|---|
| O20130226000494 | WV | Part B Supplier - Clinic/Group Practice | 0446232987 |
Receives reassigned benefits from 19 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Buckhannon, WV; Sutton, WV |
| O20151015001629 | WV | Part a Provider - Federally Qualified Health Center (FQHC) | 0446232987 | Practice locations: Bomont, WV |
National Provider Directory
Locations
167 Gawthrop Rd
#A
Buckhannon, WV 26201
Phone (304) 473-5690
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
167 Gawthrop Rd
Buckhannon, WV 26201-3927
Mailing address
PO Box 217
Rock Cave, WV 26234-0217
Phone (304) 924-6262
Other practice location 1
501 Bomont Rd
Bomont, WV 25030-9666
Phone (304) 548-7101
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2468-5535 | Other | WV | WV STATE TAX DEPT |
Other names
- Tennerton Elementary School Wellness Center
Other providers in Buckhannon, WV
- 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.
- Community Care Pharmacy of West Virginia Inc
- Conde Family Dentistry
- Andrea Conde
All providers in Buckhannon, 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 Sep 6, 2024. 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.