Provider Demographics
NPI:1457740789
Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Other - Org Name:EAU CLAIRE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DELGAOD
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:803-733-5969
Mailing Address - Fax:803-753-5591
Practice Address - Street 1:3800 N MAIN ST
Practice Address - Street 2:STE. C
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6414
Practice Address - Country:US
Practice Address - Phone:803-705-3169
Practice Address - Fax:803-705-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9183Medicaid
SCZA9183Medicaid