Healthcare Provider Details

I. General information

NPI: 1003663014
Provider Name (Legal Business Name): RICKY LEE MILBOURNE JR. CSA, LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-4802
US

IV. Provider business mailing address

5103 TANGLEWOOD CT
SUFFOLK VA
23435-2637
US

V. Phone/Fax

Practice location:
  • Phone: 757-312-6800
  • Fax:
Mailing address:
  • Phone: 703-965-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000535
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: