Healthcare Provider Details

I. General information

NPI: 1891007233
Provider Name (Legal Business Name): EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 KINARD ST
NEWBERRY SC
29108-2909
US

IV. Provider business mailing address

PO BOX 3788
COLUMBIA SC
29230-3788
US

V. Phone/Fax

Practice location:
  • Phone: 803-405-0220
  • Fax: 803-405-0222
Mailing address:
  • Phone: 803-753-5591
  • Fax: 803-753-5591

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: KIMBERLY M TILLEY
Title or Position: SR. CREDENTIALING SPECIALIST
Credential:
Phone: 804-306-1203