NPIMap

Organization Active NPI

Eau Claire Cooperative Health Center, Inc.

Doing business as Brookland Cayce Medical Practice

  • Federally Qualified Health Center (FQHC)
  • Cayce, SC
National Provider Identifier
1720399728
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.
Doing business as
Brookland Cayce Medical Practice
Practice address
1115 State St
Cayce, SC 29033-4342
Phone
(803) 939-0174
Fax
(803) 217-0282
NPI assigned
Jun 24, 2010
Last updated
Feb 3, 2022By the provider in NPPES
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
Mr. Delgado Cantave
Title
Ceo
Phone
(803) 733-5969

Specialties & licenses 1

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

Addresses

Primary practice location

1115 State St
Cayce, SC 29033-4342

Mailing address

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

Other identifiers 4

IdentifierTypeStateIssuer
FQC144MedicaidSC
FQC031MedicaidSC
4350OtherSCMEDICARE PART B
CBP018MedicaidSC

Other names 1

  • Brookland Cayce Medical Practice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040114000335 SC Part B Supplier - Clinic/Group Practice 3274434220 Receives reassigned benefits from 153 practitioners
23 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Columbia, SC; Eastover, SC; Hopkins, SC; Jenkinsville, SC; Leesville, SC; Little Mountain, SC; Newberry, SC; Pelion, SC…
O20100828000160 SC Part A Provider - Federally Qualified Health Center (FQHC) 3274434220 Practice locations: Cayce, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720399728. Details of each certification follow.

Federally qualified health center certification: CCN 421862

Legal name
EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Doing business as
BROOKLAND CAYCE MEDICAL PRACTICE
Certification status
Active
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
1115 State St
Cayce, SC 29033-4342

Other NPIs on the same Medicare enrollment 23

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 23

National Provider Directory

National Provider Directory
Tax ID family
Winnsboro Pediatrics Famil44 organizations share this tax ID, including this one

Other organizations with this tax ID 43

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

View all 43

Ownership & related parties

All disclosed owners & managing parties 13

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 DirectorBoard Member Jul 29, 2014
Ashley Jackson Individual Corporate Director Dec 1, 2016
Deborah Depaoli Individual Corporate DirectorBoard Member Jun 27, 2017
Dean Slade Individual Corporate DirectorBoard Member Jul 25, 2017
Junior Delgado Cantave Individual Corporate DirectorCeo Sep 28, 2016
W-2 Managing EmployeeCeo Sep 28, 2016
Julia Easterlin Individual Corporate DirectorBoard Member Jul 30, 2013
Julie Smithwick Individual Corporate DirectorBoard Member Sep 27, 2016
Glenn Stalions Individual Corporate DirectorTreasurer/Board Member May 31, 2016
Generett Dingle Individual Corporate Director Mar 25, 2016
Elaine Eskew Individual Corporate Director Mar 25, 2016
Gregory Torrales Individual Corporate DirectorBoard Chair (Board Chairman) Mar 25, 2014
Rafael Gonzalez Individual Corporate Director Aug 25, 2016

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": "1277337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643846400000",
    "number": "1720399728",
    "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": "1115 STATE ST",
            "city": "CAYCE",
            "state": "SC",
            "postal_code": "290334342",
            "telephone_number": "803-939-0174",
            "fax_number": "803-217-0282"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-06-24",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC144",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC031",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B",
            "identifier": "4350",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CBP018",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Brookland Cayce Medical Practice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Brookland Cayce Medical Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cayce, SC

Sources for this page

Verify at the official NPI Registry.