Healthcare Provider Details

I. General information

NPI: 1821769456
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 E TUDOR RD
ANCHORAGE AK
99503-6123
US

IV. Provider business mailing address

999 E TUDOR RD
ANCHORAGE AK
99503-6123
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-6799
  • Fax: 907-729-8607
Mailing address:
  • Phone: 907-729-6799
  • Fax: 907-729-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CRISTINA CAYANONG RANON-BACOD
Title or Position: SUPERVISOR
Credential:
Phone: 907-729-6799