MEDICARE: CHARLES SMALL

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	16459-08-013	VA

General Provider Information

NPI Number	:	1740131903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES SMALL

Provider Business Mailing Address
First Line	:	10712 TOSTON LN
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-6496
Country	:	US
Telephone Number	:	804-252-5482
Fax Number	:	804-252-5482

Provider Business Practice Location Address
First Line	:	10712 TOSTON LN
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-6496
Country	:	US
Telephone Number	:	804-252-5482
Fax Number	:	804-252-5482

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

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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Directions to “ CHARLES SMALL ” Practice Location

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