Healthcare Provider Details

I. General information

NPI: 1154231892
Provider Name (Legal Business Name): EAU CLAIRE COOPERATIVE HEALTH CENTER ,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 KINARD ST
NEWBERRY SC
29108-2909
US

IV. Provider business mailing address

2525 KINARD ST
NEWBERRY SC
29108-2909
US

V. Phone/Fax

Practice location:
  • Phone: 803-405-0220
  • Fax:
Mailing address:
  • Phone: 803-405-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY M TILLEY
Title or Position: SR. CREDENTIALING SPECIALIST
Credential:
Phone: 803-530-7855