Healthcare Provider Details

I. General information

NPI: 1093051245
Provider Name (Legal Business Name): EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 N MAIN ST
COLUMBIA SC
29203-5864
US

IV. Provider business mailing address

PO BOX 3788
COLUMBIA SC
29230-3788
US

V. Phone/Fax

Practice location:
  • Phone: 803-786-2121
  • Fax: 803-786-2124
Mailing address:
  • Phone: 803-733-5969
  • Fax: 803-217-0026

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