MEDICARE: ROY RICKETTS

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	106S00000X	Behavior Technician		NV

General Provider Information

NPI Number	:	1679104442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY RICKETTS

Provider Business Mailing Address
First Line	:	5520 OATFIELD ST
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89081-2979
Country	:	US
Telephone Number	:	702-886-7044
Fax Number	:

Provider Business Practice Location Address
First Line	:	5520 OATFIELD ST
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89081-2979
Country	:	US
Telephone Number	:	702-886-7044
Fax Number	:

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

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	01/30/2020

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Directions to “ ROY RICKETTS ” Practice Location

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