Healthcare Provider Details

I. General information

NPI: 1104490887
Provider Name (Legal Business Name): ICCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 COOPERATIVE WAY
LEBANON OR
97355-4063
US

IV. Provider business mailing address

PO BOX 4858
PORTLAND OR
97208-4858
US

V. Phone/Fax

Practice location:
  • Phone: 541-666-3305
  • Fax: 541-666-3306
Mailing address:
  • Phone: 541-500-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERICA HAUSER
Title or Position: CFO
Credential:
Phone: 312-590-5372