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General NPI Number Information
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NPI Number | 1700728052
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Entity Type | Organization
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Legal Business Name | EAU CLAIRE COOPERATIVE HEALTH CENTER ,INC.
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Dates
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Enumeration Date | 04/07/2026
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Last Update Date | 04/07/2026
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Provider Practice Location Address
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Address Line | 4809 MONTICELLO RD
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City | COLUMBIA
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State | SC
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Zip | 29203-4124
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Country | US
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Telephone | 803-888-1106
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Fax | 803-602-0035
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Provider Business Mailing Address
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Address Line | 4809 MONTICELLO RD
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City | COLUMBIA
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State | SC
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Zip | 29203-4124
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Country | US
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Telephone | 803-888-1106
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Fax | 803-602-0035
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | KIMBERLY M TILLEY
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Credential |
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Telephone | 804-306-1203
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0000X
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Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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