Healthcare Provider Details

I. General information

NPI: 1346723004
Provider Name (Legal Business Name): EAU CLAIRE COOPERTIVE HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 NORTH BROWN ST
WEST COLUMBIA SC
29169-5710
US

IV. Provider business mailing address

407 N BROWN ST
WEST COLUMBIA SC
29169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 803-722-1352
  • Fax: 803-995-8846
Mailing address:
  • Phone: 803-722-1352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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