NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as West Milford Elementary School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • West Milford, WV
National Provider Identifier
1821349309
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
2273-9509 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
West Milford Elementary School Wellness Center
Practice address
226 School St
West Milford, WV 26451-9700
Phone
(304) 326-7030
Fax
(304) 745-4488
NPI assigned
Sep 25, 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 2273-9509 WV Primary

Addresses

Primary practice location

226 School St
West Milford, WV 26451-9700

Mailing address

226 School St
West Milford, WV 26451-9700
Phone (304) 326-7030

Other names 1

  • West Milford 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
O20130226000532 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 23 practitioners
Practice locations: West Milford, WV
O20190722003573 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: West Milford, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821349309. Details of each certification follow.

Federally qualified health center certification: CCN 511011

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
WEST MILFORD ELEMENTARY SCHOLL 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
226 School St
West Milford, WV 26451-9700

National Provider Directory

National Provider Directory
Part of
Primary Care Systems Inc

Locations

182 School St
West Milford, WV 26451
Phone (304) 745-5739

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 OfficerMedical Director Sep 1, 2003
Dora L. Potasnik Individual W-2 Managing EmployeeCredentialing Coordinator Jan 9, 2012
Karen E Grant Individual Corporate DirectorBoard Secretary 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 OfficerCompliance 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 Vice President 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 74

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 74

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": "1553126400000",
    "number": "1821349309",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "226 SCHOOL ST",
            "city": "WEST MILFORD",
            "state": "WV",
            "postal_code": "264519700",
            "telephone_number": "304-326-7030",
            "fax_number": "304-745-4488"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "226 SCHOOL ST",
            "city": "WEST MILFORD",
            "state": "WV",
            "postal_code": "264519700",
            "telephone_number": "304-326-7030",
            "fax_number": "304-745-4488"
        }
    ],
    "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": "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": "2273-9509",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "West Milford Elementary School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "West Milford Elementary School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in West Milford, WV

Sources for this page

Verify at the official NPI Registry.