Basic Information
| Provider Information | |||||||||
| NPI: | 1750492906 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICCO LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COTTAGE GROVE URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1292 HIGH STREET | ||||||||
| Address2: | SUITE 224 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416416053 | ||||||||
| FaxNumber: | 5414859987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974241224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419427000 | ||||||||
| FaxNumber: | 5419425550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORLEY | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5416416053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | PA00462 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | MD10106 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | PA01017 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | MD25942 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 150890 | 05 | OR | MEDICAID | 06691900 | 01 | OR | BLUE CROSS/BLUE SHIELD | OTHER |