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General NPI Number Information
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NPI Number | 1205990041
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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 | 12/19/2006
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Last Update Date | 07/16/2019
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Provider Practice Location Address
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Address Line | 48134 HWY 58
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City | OAKRIDGE
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State | OR
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Zip | 97463
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Country | US
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Telephone | 541-782-4068
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Fax | 541-782-4113
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Provider Business Mailing Address
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Address Line | 1292 HIGH STREET SUITE 224
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City | EUGENE
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State | OR
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Zip | 97401
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Country | US
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Telephone | 541-228-3865
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Fax | 541-654-4693
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Authorized Official
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Title or Position | MEDICAL DIRECTOR - PRIMARY CARE
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Name | DR. DOUGLAS BAILEY
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Credential | M.D.
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Telephone | 541-782-4068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 8928878
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License Number State | OR
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