Provider Demographics
NPI:1679389506
Name:WEASEL BOY, ROMEO BLUE
Entity type:Individual
Prefix:
First Name:ROMEO
Middle Name:BLUE
Last Name:WEASEL BOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 GRASSLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-8855
Mailing Address - Country:US
Mailing Address - Phone:406-399-5172
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:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver