MEDICARE: EAU CLAIRE COOPERATIVE HEALTH CENTER INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1538674254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAU CLAIRE COOPERATIVE HEALTH CENTER INC.

Provider Business Mailing Address
First Line	:	PO BOX 3788
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29230-3788
Country	:	US
Telephone Number	:	803-733-5969
Fax Number	:	803-753-5591

Provider Business Practice Location Address
First Line	:	407 N BROWN ST
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-5710
Country	:	US
Telephone Number	:	803-995-8936
Fax Number	:	803-995-8851

Authorized Official
Title or Position	:	CEO
Name	:	DELGADO CANTAVE
Credential	:
Telephone Number	:	803-733-5969

Provider Enumeration Date	:	12/04/2017
Last Update Date	:	02/03/2022

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