1750492906 NPI number — ICCO LLC

Table of content: (NPI 1750492906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750492906 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:
COTTAGE GROVE URGENT CARE
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:
1750492906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
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:
541-641-6053
Provider Business Mailing Address Fax Number:
541-485-9987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1445 GATEWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COTTAGE GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97424-1224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-942-7000
Provider Business Practice Location Address Fax Number:
541-942-5550
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORLEY
Authorized Official First Name:
ALEXANDER
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
541-641-6053

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  MD25942 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , with the licence number: PA00462 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: MD10106 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: PA01017 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 150890 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06691900 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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