Basic Information
| Provider Information | |||||||||
| NPI: | 1336725233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICCO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BESTMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4858 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084858 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1445 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974241224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419427000 | ||||||||
| FaxNumber: | 5419984571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAUSER | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3125905372 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.