Healthcare Provider Details

I. General information

NPI: 1063806842
Provider Name (Legal Business Name): ICCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35859 HIGHWAY 58
PLEASANT HILL OR
97455-9651
US

IV. Provider business mailing address

PO BOX 4858
PORTLAND OR
97208-4858
US

V. Phone/Fax

Practice location:
  • Phone: 541-345-8760
  • Fax: 541-345-8763
Mailing address:
  • Phone: 541-500-2555
  • Fax: 541-500-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateOR

VIII. Authorized Official

Name: ALEXANDER K MORLEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 541-988-7300