Provider Demographics
NPI:1619558640
Name:ICCO, LLC
Entity Type:Organization
Organization Name:ICCO, LLC
Other - Org Name:BESTMED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-590-5372
Mailing Address - Street 1:PO BOX 4858
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:186 W ELLENDALE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1408
Practice Address - Country:US
Practice Address - Phone:971-900-4984
Practice Address - Fax:971-900-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health