Provider Demographics
NPI:1750492906
Name:ICCO LLC
Entity Type:Organization
Organization Name:ICCO LLC
Other - Org Name:COTTAGE GROVE URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-641-6053
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:541-641-6053
Mailing Address - Fax:541-485-9987
Practice Address - Street 1:1445 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1224
Practice Address - Country:US
Practice Address - Phone:541-942-7000
Practice Address - Fax:541-942-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25942261Q00000X
ORPA00462261Q00000X
ORMD10106261Q00000X
ORPA01017261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150890Medicaid
OR06691900OtherBLUE CROSS/BLUE SHIELD
OR06691900OtherBLUE CROSS/BLUE SHIELD
OR150890Medicaid