Provider Demographics
NPI:1326267592
Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Other - Org Name:LAKE MONTICELLO FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DELGADO
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-733-5969
Mailing Address - Street 1:PO BOX 3788
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3788
Mailing Address - Country:US
Mailing Address - Phone:803-753-5591
Mailing Address - Fax:803-753-5591
Practice Address - Street 1:9017 STATE HIGHWAY 215 S
Practice Address - Street 2:
Practice Address - City:JENKINSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29065-9428
Practice Address - Country:US
Practice Address - Phone:803-298-2068
Practice Address - Fax:803-298-2069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC126Medicaid
SCCBP018Medicaid
SCFQC031Medicaid
SCFQC126Medicaid
SC4350Medicare PIN