NPIMap

Organization Active NPI

Community Care of West Virginia, Inc.

Doing business as Community Care of Big Otter

  • Federally Qualified Health Center (FQHC)
  • Ivydale, WV
National Provider Identifier
1992754592
Registry record updated Jan 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
550630765002 Issued in WV
Legal business name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
Community Care of Big Otter
Practice address
797 Clinic Dr
Ivydale, WV 25113-8263
Phone
(304) 286-4200
Fax
(304) 286-2107
NPI assigned
May 9, 2006
Last updated
Jan 19, 2024By 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 Jan 19, 2024

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 550630765002 WV Primary

Addresses

Primary practice location

797 Clinic Dr
Ivydale, WV 25113-8263

Mailing address

PO Box 147
Clay, WV 25043-0147
Phone (304) 587-7301

Other identifiers 2

IdentifierTypeStateIssuer
0035398000MedicaidWV
001898548OtherWVMS BCBS

Other names 1

  • Community Care of Big Otter Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20071024000166 WV Part B Supplier - Public Health/Welfare Agency 0446232987 Receives reassigned benefits from 74 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clay, WV; Buckhannon, WV; West Milford, WV; Rock Cave, WV; Marlinton, WV; Ivydale, WV; Helvetia, WV; Green Bank, WV…
O20120904000371 WV Part A Provider - Federally Qualified Health Center (FQHC) 0446232987 Practice locations: Ivydale, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1992754592. Details of each certification follow.

Federally qualified health center certification: CCN 511864

Legal name
COMMUNITY CARE OF WEST VIRGINIA, INC.
Doing business as
COMMUNITY CARE OF BIG OTTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 17, 1998
Last certification
Mar 17, 1998
Ownership / control type
For profit – corporation
Most recent change of ownership
Sep 1, 2012 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1984 in WV
Enrollment address
797 Clinic Dr
Ivydale, WV 25113-8263

Other NPIs on the same Medicare enrollment 14

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

View all 14

National Provider Directory

National Provider Directory
Tax ID family
Big Otter Elementary School Wellness Center7 organizations share this tax ID, including this one
Part of
Community Care of West Virginia

Other organizations with this tax ID 6

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

Locations

797 Clinic Dr
Ivydale, WV 25113
Phone (304) 286-4200

Ownership & related parties

All disclosed owners & managing parties 22

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Dora L. Potasnik Individual W-2 Managing EmployeeCredentialing Jan 9, 2012
Kristi Walkr Individual Corporate OfficerCoo Oct 15, 2022
Gina Stalnaker Individual Corporate DirectorBoard Member Feb 20, 2024
Juston Chad Morrison Individual Corporate DirectorBoard Member Apr 10, 2017
Elisabeth M Samples Individual Corporate DirectorBoard Secretary Jan 1, 2018
Michele Williams Individual Corporate OfficerCompliance Officer Dec 12, 2005
Jeffrey Jenkins Individual Corporate Officer Apr 4, 2022
Everett Hoffman Individual Corporate DirectorBoard Member Feb 20, 2024
David B Malcomb Individual Corporate DirectorBoard Vice-President Jan 1, 2018
David D Taylor Individual Corporate DirectorBoard Member Mar 14, 2016
Abigail Friend Individual W-2 Managing EmployeeCredentialing Coordinator Aug 1, 2023
Katherine Anne Horner Individual Corporate OfficerBoard Member Jan 14, 2019
Kimberly Renee Becher Individual Corporate OfficerChief Medical Officer Sep 23, 2021
Melanie Horn Individual W-2 Managing EmployeeCredentialing Manager Aug 26, 2024
Leah Grose Individual W-2 Managing EmployeeCredentialing Coordinator Jul 14, 2025
Patricia Louise Collett Individual Corporate OfficerCeo Nov 18, 2000 100%
Shelly Gause Individual W-2 Managing EmployeeCredentialing Coordinator Jan 28, 2023
Rosemary M Thomas Individual Corporate DirectorBoard President Jan 1, 2020
Lawrence Boggs Individual Corporate DirectorBoard Member Jan 1, 2023
James L Estep Individual Corporate DirectorBoard Treasurer Jan 1, 2020
Sarina Smith Individual Corporate DirectorBoard Member Jan 14, 2019
Kevin Douglas Junkins Individual Corporate OfficerCmo for Behavioral Health Jun 9, 2017

Owners & managing parties with NPI records 3

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": "1147132800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705622400000",
    "number": "1992754592",
    "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": "304-587-7301",
            "fax_number": "304-587-2464"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "797 CLINIC DR",
            "city": "IVYDALE",
            "state": "WV",
            "postal_code": "251138263",
            "telephone_number": "304-286-4200",
            "fax_number": "304-286-2107"
        }
    ],
    "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": "2006-05-09",
        "last_updated": "2024-01-19",
        "certification_date": "2024-01-19",
        "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": "550630765002",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0035398000",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MS BCBS",
            "identifier": "001898548",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Care of Big Otter",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ivydale, WV

Sources for this page

Verify at the official NPI Registry.