Provider Demographics
NPI:1700251154
Name:ICCO LLC
Entity Type:Organization
Organization Name:ICCO LLC
Other - Org Name:EUGENE URGENT CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:HUNSUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-521-7222
Mailing Address - Street 1:1292 HIGH ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3238
Mailing Address - Country:US
Mailing Address - Phone:541-345-2860
Mailing Address - Fax:541-345-8763
Practice Address - Street 1:1292 HIGH STREET
Practice Address - Street 2:SUITE 224
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-345-8760
Practice Address - Fax:541-345-8763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA175527363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA175527OtherOREGON MEDICAL BOARD STATE LICENSE FOR PHYSICIAN ASSISTANT