Provider Demographics
NPI:1528356953
Name:ICCO, LLC
Entity Type:Organization
Organization Name:ICCO, LLC
Other - Org Name:THURSTON URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:MORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-654-0282
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1377
Mailing Address - Country:US
Mailing Address - Phone:541-228-3660
Mailing Address - Fax:541-228-3670
Practice Address - Street 1:5781 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-5426
Practice Address - Country:US
Practice Address - Phone:541-636-3473
Practice Address - Fax:541-363-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR145612Medicare PIN