Provider Demographics
NPI:1528385754
Name:ICCO, LLC
Entity Type:Organization
Organization Name:ICCO, LLC
Other - Org Name:NOVA HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:CLENDENEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-799-1150
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 1:1800 COBURG RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4995
Practice Address - Country:US
Practice Address - Phone:541-342-1632
Practice Address - Fax:541-345-8763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty