NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Buckhannon Upshur Middle School Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Buckhannon, WV
National Provider Identifier
1992144273
Registry record updated Jun 19, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
2287-7364 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Buckhannon Upshur Middle School Wellness Center
Practice address
RR 6 Box 303
Buckhannon, WV 26201-8830
Phone
(304) 472-1520
Fax
(304) 472-6864
NPI assigned
Jun 19, 2013
Last updated
Jun 19, 2013By 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 Jun 19, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dora L Potasnik
Title
Credentialing
Phone
(304) 587-2541

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 2287-7364 WV Primary

Addresses

Primary practice location

RR 6 Box 303
Buckhannon, WV 26201-8830

Mailing address

PO Box 217
Rock Cave, WV 26234-0217
Phone (304) 924-6262

Other identifiers 1

IdentifierTypeStateIssuer
2287-7374OtherWVBUSINESS LICENSE

Other names 1

  • Buckhannon Upshur Middle School Wellness Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20131028001724 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Buckhannon, WV
O20131029001913 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Buckhannon, WV
O20140407000404 WV Part B Supplier - Clinic/Group Practice 0446232987 Receives reassigned benefits from 25 practitioners
Practice locations: Buckhannon, WV

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1992144273. Details of each certification follow.

Federally qualified health center certification: CCN 511039

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
BUCKHANNON-UPSHUR MIDDLE SCHOOL WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 5, 2013
Last certification
Nov 5, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
303 RR 6
Buckhannon, WV 26201-8830

Federally qualified health center certification: CCN 511038

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
BUCKHANNON-UPSHUR MIDDLE SCHOOL WELNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 5, 2013
Last certification
Nov 5, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
303 RR 6
Buckhannon, WV 26201-8830

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Tri County Health Clinic Inc

Ownership & related parties

All disclosed owners & managing parties 17

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 OfficerCmo Sep 1, 2003
Corporate OfficerChief Medical Officer Nov 5, 2013
Dora L. Potasnik Individual W-2 Managing EmployeeCredentialing Sep 16, 2013
W-2 Managing EmployeeCredentialing Jan 9, 2012
Juston Chad Morrison Individual Corporate Director Apr 10, 2017
Corporate DirectorBoard Member Jan 1, 2020
Hillary Nicole Tenney Individual W-2 Managing EmployeeCredentialing Coordinator Aug 1, 2018
W-2 Managing EmployeeCredentialing Coordinator Aug 1, 2019
Elisabeth M Samples Individual Corporate DirectorBoard Secretary Jan 1, 2018
Michele Williams Individual Corporate OfficerCompliance Officer Dec 12, 2005
Corporate OfficerCompliance Officer Nov 5, 2013
Jeffrey Jenkins Individual Corporate OfficerCfo Apr 4, 2022
Richard G Simon Individual Corporate OfficerCeo Sep 13, 1993 100%
David B Malcomb Individual Corporate Director Jan 1, 2018
Corporate DirectorBoard Member Jan 1, 2020
Selah Raines Individual Corporate Director Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
David D Taylor Individual Corporate Director Mar 14, 2016
Corporate DirectorBoard Member Mar 14, 2016
Katherine Anne Horner Individual Corporate DirectorBoard Vice- President Jan 14, 2019
Corporate DirectorBoard Vice-President Jan 14, 2019
Patricia Louise Collett Individual Corporate OfficerCoo Nov 18, 2000
Corporate OfficerCoo Nov 5, 2013
Steven Roy Flaughers Individual Corporate Director Jan 14, 2019
Corporate DirectorBoard Member Jan 14, 2019
Rosemary M Thomas Individual Corporate DirectorBoard President Jan 1, 2020
James L Estep Individual Corporate DirectorBoard Treasurer Jan 1, 2020
Sarina Smith Individual Corporate Director Jan 14, 2019
Corporate DirectorBoard Member Jan 14, 2019

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 97

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 97

NPI Registry JSON

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

{
    "created_epoch": "1371600000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1371600000000",
    "number": "1992144273",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 217",
            "city": "ROCK CAVE",
            "state": "WV",
            "postal_code": "262340217",
            "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": "RR 6 BOX 303",
            "city": "BUCKHANNON",
            "state": "WV",
            "postal_code": "262018830",
            "telephone_number": "304-472-1520",
            "fax_number": "304-472-6864"
        }
    ],
    "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": "2013-06-19",
        "last_updated": "2013-06-19",
        "status": "A",
        "authorized_official_last_name": "POTASNIK",
        "authorized_official_first_name": "DORA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "304-587-2541"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WV",
            "license": "2287-7364",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BUSINESS LICENSE",
            "identifier": "2287-7374",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Buckhannon Upshur Middle School Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Buckhannon, WV

Sources for this page

Verify at the official NPI Registry.