Healthcare Provider Details

I. General information

NPI: 1437660768
Provider Name (Legal Business Name): ICCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

598 E 13TH AVE
EUGENE OR
97401-4783
US

IV. Provider business mailing address

1292 HIGH ST STE 224
EUGENE OR
97401-3238
US

V. Phone/Fax

Practice location:
  • Phone: 541-844-0233
  • Fax: 541-505-7486
Mailing address:
  • Phone: 541-228-3865
  • Fax: 541-654-4693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LORA PETERSON
Title or Position: CLINIC MANAGER
Credential:
Phone: 541-541-8440