Provider Demographics
NPI:1578928818
Name:ICCO LLC
Entity Type:Organization
Organization Name:ICCO LLC
Other - Org Name:PRIME CARE PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-255-3233
Mailing Address - Street 1:1292 HIGH STREET
Mailing Address - Street 2:SUITE 224
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-228-3865
Mailing Address - Fax:541-345-8763
Practice Address - Street 1:1800 COBURG ROAD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-255-3233
Practice Address - Fax:541-255-2452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDP1360OtherRR MEDICARE PTAN
ORDP1360OtherRR MEDICARE PTAN