Healthcare Provider Details

I. General information

NPI: 1063159267
Provider Name (Legal Business Name): EAU CLAIRE COOPERATIVE HEALTH CENTER ,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/18/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ATRIUM WAY STE 120
COLUMBIA SC
29223-6382
US

IV. Provider business mailing address

169 LAURELHURST AVE
COLUMBIA SC
29210-3825
US

V. Phone/Fax

Practice location:
  • Phone: 803-875-8020
  • Fax: 803-626-0742
Mailing address:
  • Phone: 803-733-5969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DELGADO CANTAVE
Title or Position: CEO
Credential:
Phone: 803-733-5969