Provider Demographics
NPI:1003663014
Name:MILBOURNE, RICKY LEE JR (CSA, LSA)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:LEE
Last Name:MILBOURNE
Suffix:JR
Gender:M
Credentials:CSA, LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5103 TANGLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2637
Mailing Address - Country:US
Mailing Address - Phone:703-965-6239
Mailing Address - Fax:
Practice Address - Street 1:844 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4802
Practice Address - Country:US
Practice Address - Phone:757-312-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000535246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant