Provider Demographics
NPI:1992018949
Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC
Entity Type:Organization
Organization Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC
Other - Org Name:EAU CLAIRE BEHAVIORAL MEDICINE
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:MD
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 1:4605 MONTICELLO RD
Practice Address - Street 2:BUILDING B, STE.1
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4156
Practice Address - Country:US
Practice Address - Phone:803-714-0266
Practice Address - Fax:803-753-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC187Medicaid
SCCBP018Medicaid
SCFQC031Medicaid
SCFQC031Medicaid
SCFQC187Medicaid