Provider Demographics
NPI:1902131022
Name:ICCO, LLC
Entity Type:Organization
Organization Name:ICCO, LLC
Other - Org Name:EUGENE URGENT CARE-COBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-636-3473
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:1800 COBURG ROAD
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1377
Mailing Address - Country:US
Mailing Address - Phone:541-345-8760
Mailing Address - Fax:541-345-8763
Practice Address - Street 1:1800 COBURG RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4945
Practice Address - Country:US
Practice Address - Phone:541-345-8760
Practice Address - Fax:541-345-8763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
R145612Medicare PIN