MEDICARE: SOUTHCENTRAL FOUNDATION

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	261QC1500X	Community Health Clinic/Center	20467	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043632037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHCENTRAL FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 35198
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98124-5198
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11495 N CALLISON STREET
Second Line	:
City	:	SUTTON
State	:	AK
Zip	:	99674
Country	:	US
Telephone Number	:	907-631-7665
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT OF FINANCE
Name	:	RONALD LEE OLSON
Credential	:
Telephone Number	:	907-729-4939

Provider Enumeration Date	:	01/10/2014
Last Update Date	:	08/30/2023

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Directions to “SOUTHCENTRAL FOUNDATION ” Practice Location

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