Provider Demographics
NPI:1518990621
Name:ICCO, LLC
Entity type:Organization
Organization Name:ICCO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-935-2200
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:VENETA
Mailing Address - State:OR
Mailing Address - Zip Code:97487
Mailing Address - Country:US
Mailing Address - Phone:541-935-2200
Mailing Address - Fax:541-935-6241
Practice Address - Street 1:87983 TERRITORIAL RD
Practice Address - Street 2:
Practice Address - City:VENETA
Practice Address - State:OR
Practice Address - Zip Code:97487
Practice Address - Country:US
Practice Address - Phone:541-935-2200
Practice Address - Fax:541-935-6241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR054077Medicaid
OR054077Medicaid