=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740896547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2020
-----------------------------------------------------
Last Update Date | 06/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4480 HIGHWAY 101 STE G
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97439-8831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 458-215-2185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4858
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97208-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ERICA HAUSER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-590-5372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------