Healthcare Provider Details

I. General information

NPI: 1114236429
Provider Name (Legal Business Name): ANNA L BLACKFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 39 G RD
SAGLE ID
83860-8960
US

IV. Provider business mailing address

PO BOX 573
PONDERAY ID
83852-0573
US

V. Phone/Fax

Practice location:
  • Phone: 208-290-1079
  • Fax:
Mailing address:
  • Phone: 208-290-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberQK307464B
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: