MEDICARE: MR. RICKY RANDALL LAPRADD JR. A.T.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	0126000966	VA

General Provider Information

NPI Number	:	1063489946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICKY RANDALL LAPRADD JR. A.T.C.

Provider Business Mailing Address
First Line	:	5721 SIERRA DR
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24012-1111
Country	:	US
Telephone Number	:	540-793-4739
Fax Number	:

Provider Business Practice Location Address
First Line	:	2102 GRANDIN RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-3528
Country	:	US
Telephone Number	:	540-853-2158
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	06/13/2008

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