Basic Information
| Provider Information | |||||||||
| NPI: | 1528498995 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICCO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROSEBURG URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1292 HIGH ST | ||||||||
| Address2: | SUITE #224 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416363473 | ||||||||
| FaxNumber: | 5416363480 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 NW GOETZ ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413458760 | ||||||||
| FaxNumber: | 5413458763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | MORLEY | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5416363473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.