NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Burnsville Elementary School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Burnsville, WV
National Provider Identifier
1871003178
Registry record updated Oct 2, 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
Burnsville Elementary School Wellness Center
Practice address
228 Kanawha Avenue
Burnsville, WV 26335
Phone
(304) 924-6262
Fax
(304) 924-5460
NPI assigned
Oct 2, 2017
Last updated
Oct 2, 2017By 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 Oct 2, 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

228 Kanawha Avenue
Burnsville, WV 26335

Mailing address

PO Box 147
Clay, WV 25043-0147
Phone (304) 587-2541

Other names 1

  • Burnsville 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
O20171116003214 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Burnsville, WV
O20180321000951 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 5 practitioners
Practice locations: Burnsville, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871003178. Details of each certification follow.

Federally qualified health center certification: CCN 511132

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
BURNSVILLE ELEMENTARY SCHOOL WELL CTR
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 10, 2017
Last certification
Oct 10, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
228 Kanawha Ave
Burnsville, WV 26335-7700

National Provider Directory

National Provider Directory
Tax ID family
Tri County Health Clinic Inc19 organizations share this tax ID, including this one
Part of
Tri County Health Clinic Inc

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 16

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 Member Apr 1, 2011
Thomas G Lynch Individual Corporate DirectorBoard President Jul 1, 2007
Michele Williams Individual Corporate OfficerCompliance Officer Dec 12, 2005
Corporate DirectorBoard Member Dec 12, 2005
Richard G Simon Individual Corporate OfficerCeo Sep 13, 1993 100%
Corporate DirectorBoard Member Sep 13, 1993
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 Member Jul 1, 2007
Katherine Anne Horner Individual Corporate DirectorBoard Vice President Jan 14, 2019
Brock M Malcolm Individual Corporate OfficerCoo Aug 1, 2007
Patricia Louise Collett Individual Corporate OfficerCeo Jan 18, 2000 100%
Corporate DirectorDirector of Medical Services Nov 18, 2000
Steven Roy Flaughers Individual Corporate DirectorBoard Member Jan 14, 2019
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 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1506902400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1506902400000",
    "number": "1871003178",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 147",
            "city": "CLAY",
            "state": "WV",
            "postal_code": "250430147",
            "telephone_number": "304-587-2541",
            "fax_number": "304-587-2594"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "228 KANAWHA AVENUE",
            "city": "BURNSVILLE",
            "state": "WV",
            "postal_code": "26335",
            "telephone_number": "304-924-6262",
            "fax_number": "304-924-5460"
        }
    ],
    "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": "2017-10-02",
        "last_updated": "2017-10-02",
        "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": "Burnsville Elementary School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Burnsville, WV

Sources for this page

Verify at the official NPI Registry.