1467795815 NPI number — EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.

Table of content: MALLORIE LEEANN SHEPARD LPC INTERN (NPI 1154091544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467795815 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:
Provider Other Organization Name Type Code:
6
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:
1467795815
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:
4605 MONTICELLO RD
Provider Second Line Business Practice Location Address:
BLDGB, STE.2
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-4156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-753-5590
Provider Business Practice Location Address Fax Number:
803-753-5592
Provider Enumeration Date:
04/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
STUART
Authorized Official Middle Name:
A
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: FQC179 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: FQC031 , 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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