Provider Demographics
NPI:1437660768
Name:ICCO, LLC
Entity Type:Organization
Organization Name:ICCO, LLC
Other - Org Name:MUSCULOSKELETAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-541-8440
Mailing Address - Street 1:1292 HIGH ST STE 224
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3238
Mailing Address - Country:US
Mailing Address - Phone:541-228-3865
Mailing Address - Fax:541-654-4693
Practice Address - Street 1:598 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4783
Practice Address - Country:US
Practice Address - Phone:541-844-0233
Practice Address - Fax:541-505-7486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty