Healthcare Provider Details

I. General information

NPI: 1164669040
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 DIPLOMACY DR
ANCHORAGE AK
99508-5925
US

IV. Provider business mailing address

4501 DIPLOMACY DR
ANCHORAGE AK
99508-5919
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-3300
  • Fax:
Mailing address:
  • Phone: 907-729-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number20467
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number20467
License Number StateAK

VIII. Authorized Official

Name: RONALD LEE OLSON
Title or Position: VP FINANCE
Credential:
Phone: 907-729-4939