Individual
ANNA L BLACKFORD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
455 39 G RD, SAGLE, ID 83860-8960
(208) 290-1079
Mailing address
PO BOX 573, PONDERAY, ID 83852-0573
(208) 290-1079
Taxonomy
Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
QK307464B
ID
Other
Enumeration date
10/04/2010
Last updated
10/04/2010
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