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General NPI Number Information
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NPI Number | 1104490887
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Entity Type | Organization
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Legal Business Name | ICCO, LLC
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Dates
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Enumeration Date | 05/17/2021
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Last Update Date | 06/20/2022
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Provider Practice Location Address
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Address Line | 3400 COOPERATIVE WAY
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City | LEBANON
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State | OR
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Zip | 97355-4063
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Country | US
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Telephone | 541-666-3305
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Fax | 541-666-3306
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Provider Business Mailing Address
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Address Line | PO BOX 4858
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City | PORTLAND
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State | OR
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Zip | 97208-4858
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Country | US
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Telephone | 541-500-2555
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | ERICA HAUSER
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Credential |
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Telephone | 312-590-5372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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