1003113168 NPI number — EAU CLAIRE COOPERATIVE HEALTH CENTER, INC

Table of content: (NPI 1003113168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003113168 NPI number — EAU CLAIRE COOPERATIVE HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAU CLAIRE COOPERATIVE HEALTH CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WINNSBORO PEDIATRICS & FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003113168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3788
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29230-3788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-733-5969
Provider Business Mailing Address Fax Number:
803-753-5591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 KINCAID BRIDGE RD
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
WINNSBORO
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29180-7116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-635-1052
Provider Business Practice Location Address Fax Number:
803-712-9724
Provider Enumeration Date:
02/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CANTAVE
Authorized Official First Name:
DELGADO
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
803-733-5969

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FQC031 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: FQC133 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CBP018 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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