Basic Information
| Provider Information | |||||||||
| NPI: | 1205990041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICCO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIVE RIVERS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1292 HIGH STREET | ||||||||
| Address2: | SUITE 224 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412283865 | ||||||||
| FaxNumber: | 5416544693 | ||||||||
| Practice Location | |||||||||
| Address1: | 48134 HWY 58 | ||||||||
| Address2: | |||||||||
| City: | OAKRIDGE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417824068 | ||||||||
| FaxNumber: | 5417824113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAILEY | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR - PRIMARY CARE | ||||||||
| AuthorizedOfficialTelephone: | 5417824068 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 8928878 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.