1205990041 NPI number — ICCO LLC

Table of content: (NPI 1205990041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205990041 NPI number — ICCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICCO LLC
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:
FIVE RIVERS 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:
1205990041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1292 HIGH STREET
Provider Second Line Business Mailing Address:
SUITE 224
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-228-3865
Provider Business Mailing Address Fax Number:
541-654-4693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48134 HWY 58
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKRIDGE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-782-4068
Provider Business Practice Location Address Fax Number:
541-782-4113
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR - PRIMARY CARE
Authorized Official Telephone Number:
541-782-4068

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  8928878 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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