NPIMap

Organization Active NPI

Eau Claire Cooperative Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Columbia, SC
National Provider Identifier
1447561527
Registry record updated Feb 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EAU CLAIRE COOPERATIVE HEALTH CENTER, INC
Practice address
4605 Monticello Rd
BLDG a, Ste.3
Columbia, SC 29203-4156
Phone
(803) 754-0151
Fax
(803) 691-1778
NPI assigned
Jun 23, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 3, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Delgado Cantave
Title
Ceo
Phone
(803) 733-5969

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

4605 Monticello Rd
BLDG a, Ste.3
Columbia, SC 29203-4156

Mailing address

PO Box 3788
Columbia, SC 29230-3788
Phone (803) 733-5969

Other identifiers 3

IdentifierTypeStateIssuer
FQC031MedicaidSC
FQC141MedicaidSC
CBP018MedicaidSC

Other names 1

  • Eau Claire Internal Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20121224000020 SC Part A Provider - Federally Qualified Health Center (FQHC) 3274434220 Practice locations: Columbia, SC

Federally qualified health center certification: CCN 421864

Legal name
EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Doing business as
EAU CLAIRE INTERNAL MEDICINE
Certification status
Terminated Other: provider status change, May 9, 2000
Provider type (POS)
Federally qualified health center
Participating since
May 8, 2000
Last certification
May 8, 2000
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Dec 14, 1992 in SC
Enrollment address
4605 Monticello Rd
Columbia, SC 29203-4156

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
42D0907270Eau Claire Internal Medicine4605 Monticello Road, Columbia, SC 29203Certificate of waiverOct 28, 2027

National Provider Directory

National Provider Directory
Tax ID family
Eau Claire Cooperative Health Center Inc42 organizations share this tax ID, including this one

Other organizations with this tax ID 41

Organizations that report the same tax identification number in the National Provider Directory.

View all 41

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Bernice Kennedy Individual Corporate Director Mar 25, 2014
Craig Currey Individual Corporate DirectorTreasurer Jul 29, 2014
Ashley Jackson Individual Corporate Director Jun 25, 2013
Deborah Depaoli Individual Corporate DirectorSecretary Jun 27, 2017
Dean Slade Individual Corporate DirectorBoard Member Jul 25, 2017
Karena S White Individual Corporate Director Dec 21, 2020
W-2 Managing EmployeeCfo Dec 21, 2020
Junior Delgado Cantave Individual Corporate DirectorCeo Jan 1, 2016
W-2 Managing EmployeeCeo Jan 1, 2016
Julia Easterlin Individual Corporate DirectorBoard Member Jul 30, 2013
Julie Smithwick Individual Corporate DirectorBoard Member Sep 27, 2016
Glenn Stalions Individual Corporate DirectorBoard Member May 31, 2016
Gregory Torrales Individual Corporate DirectorTreasurer Mar 25, 2014

All facility ownership & control disclosures 14

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Eau Claire Cooperative Health Center, Inc.Columbia, SC, CCN 421843 Federally qualified health center 5% Or Greater Direct Ownership Interest Jan 1, 2019
Eastover Family PracticeEastover, SC, CCN 421960 Federally qualified health center Operational/Managerial Control Jan 26, 2012
Pediatrics of NewberryNewberry, SC, CCN 421970 Federally qualified health center 5% Or Greater Direct Ownership Interest Jul 1, 2014
Waverly Women'S Health & Internal MedicineBatesburg Leesville, SC, CCN 421974 Federally qualified health center 5% Or Greater Direct Ownership Interest Jun 1, 2010
Eau Claire PodiatryColumbia, SC, CCN 421968 Federally qualified health center 5% Or Greater Direct Ownership Interest Mar 7, 2022
Sterling Sharpe PediatricsSuite 1, SC, CCN 421972 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 4, 2014
Pelion Pediatrics Family & DentalPelion, SC, CCN 421977 Federally qualified health center 5% Or Greater Direct Ownership Interest Oct 19, 2012
Brookland Community PediatricsWest Columbia, SC, CCN 421978 Federally qualified health center 5% Or Greater Direct Ownership Interest Jul 1, 2010
Pediatrics of Batesburg-LeesburgBatesburg-Leesville, SC, CCN 421980 Federally qualified health center 5% Or Greater Direct Ownership Interest Oct 30, 2012
Eau Claire Walk-inColumbia, SC, CCN 421023 Federally qualified health center 5% Or Greater Direct Ownership Interest Mar 7, 2022
Five Points Behavioral Health at Hand Middle SchoolColumbia, SC, CCN 421064 Federally qualified health center Operational/Managerial Control Jan 1, 2016
Eau Claire Cooperative Health Center, Inc.Little Mountain, SC, CCN 421068 Federally qualified health center Operational/Managerial Control Jan 1, 2016
Columbia Community Family PracticeColumbia, SC, CCN 871035 Federally qualified health center 5% Or Greater Direct Ownership Interest Jan 1, 2016
Advantage Eye CareColumbia, SC, CCN 871038 Federally qualified health center 5% Or Greater Direct Ownership Interest Jun 1, 2022

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1277251200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643846400000",
    "number": "1447561527",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3788",
            "city": "COLUMBIA",
            "state": "SC",
            "postal_code": "292303788",
            "telephone_number": "803-733-5969",
            "fax_number": "803-753-5591"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4605 MONTICELLO RD",
            "address_2": "BLDG A, STE.3",
            "city": "COLUMBIA",
            "state": "SC",
            "postal_code": "292034156",
            "telephone_number": "803-754-0151",
            "fax_number": "803-691-1778"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAU CLAIRE COOPERATIVE HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-06-23",
        "last_updated": "2022-02-03",
        "certification_date": "2022-02-03",
        "status": "A",
        "authorized_official_last_name": "CANTAVE",
        "authorized_official_first_name": "DELGADO",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "803-733-5969"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC031",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC141",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CBP018",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Eau Claire Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Eau Claire Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Columbia, SC

Sources for this page

Verify at the official NPI Registry.