Basic Information
| Provider Information | |||||||||
| NPI: | 1902131022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICCO, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EUGENE URGENT CARE-COBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1377 | ||||||||
| Address2: | 1800 COBURG ROAD | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974401377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413458760 | ||||||||
| FaxNumber: | 5413458763 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 COBURG RD | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974014945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413458760 | ||||||||
| FaxNumber: | 5413458763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORLEY | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5416363473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.