MEDICARE: LARALEIGH ROBERTS ATC

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer	2879	AL

General Provider Information

NPI Number	:	1174233449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARALEIGH ROBERTS ATC

Provider Business Mailing Address
First Line	:	4182 WILD DUCK DR
Second Line	:
City	:	LAUDERDALE
State	:	MS
Zip	:	39335-9515
Country	:	US
Telephone Number	:	601-604-9983
Fax Number	:

Provider Business Practice Location Address
First Line	:	4182 WILD DUCK DR
Second Line	:
City	:	LAUDERDALE
State	:	MS
Zip	:	39335-9515
Country	:	US
Telephone Number	:	601-604-9983
Fax Number	:

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

Provider Enumeration Date	:	11/28/2022
Last Update Date	:	09/23/2024

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Directions to “ LARALEIGH ROBERTS ATC” Practice Location

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