Organization
EAU CLAIRE COOPERATIVE HEALTH CENTER, INC.
Active
Other names
Lake Monticello Family Practice @McCrorey Liston
Organization subpart
No
Provider details
NPI number
Authorized official
DELGADO CANTAVE (CEO)
(803) 733-5969
Entity
Organization
Contact information
Practice address
1978 STATE HIGHWAY 215 S, BLAIR, SC 29015-9443
(803) 402-6782
(803) 635-6628
Mailing address
PO BOX 3788, COLUMBIA, SC 29230-3788
(803) 733-5969
(803) 753-5591
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
CBP018
—
SC
05
—
FQC031
—
SC
05
—
FQC180
—
SC
Enumeration date
01/22/2015
Last updated
02/10/2022
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