Provider Demographics
NPI:1083159503
Name:ICCO, LLC
Entity Type:Organization
Organization Name:ICCO, LLC
Other - Org Name:PRIME CARE PARTNERS VENETA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:OCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-935-2200
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:25045 DUNHAM AVENUE
Mailing Address - City:VENETA
Mailing Address - State:OR
Mailing Address - Zip Code:97487-0819
Mailing Address - Country:US
Mailing Address - Phone:541-935-2035
Mailing Address - Fax:
Practice Address - Street 1:25045 DUNHAM AVENUE
Practice Address - Street 2:
Practice Address - City:VENETA
Practice Address - State:OR
Practice Address - Zip Code:97487
Practice Address - Country:US
Practice Address - Phone:541-935-2035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center