Provider Demographics
NPI:1639612880
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:541-228-3865
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:541-654-4693
Practice Address - Street 1:5781 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478
Practice Address - Country:US
Practice Address - Phone:541-654-5245
Practice Address - Fax:541-844-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
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