Provider Demographics
NPI:1972300366
Name:SMALL, THERON
Entity type:Individual
Prefix:
First Name:THERON
Middle Name:
Last Name:SMALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2048 HAYSTACK LOOP
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521
Mailing Address - Country:US
Mailing Address - Phone:406-399-3512
Mailing Address - Fax:
Practice Address - Street 1:ROCKY BOY HEALTH CENTER
Practice Address - Street 2:6850 UPPER BOX ELDER RD
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-BHPS-CRT-39077175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist