Provider Demographics
NPI:1811294978
Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Entity type:Organization
Organization Name:EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:803-733-5969
Mailing Address - Fax:803-252-5624
Practice Address - Street 1:3041 OLD EASTOVER ROAD
Practice Address - Street 2:
Practice Address - City:EASTOVER
Practice Address - State:SC
Practice Address - Zip Code:29044-2417
Practice Address - Country:US
Practice Address - Phone:803-353-8741
Practice Address - Fax:803-353-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCBP018Medicaid
SCFQC031Medicaid
SCFQC132Medicaid
SC4350Medicare PIN
SC421843Medicare PIN
SCFQC031Medicaid