Healthcare Provider Details

I. General information

NPI: 1710149661
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 COTTONWOOD ST
ANCHORAGE AK
99508-4352
US

IV. Provider business mailing address

4501 DIPLOMACY DR ATTN: PROVIDER ENROLLMENT
ANCHORAGE AK
99508-5919
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2500
  • Fax:
Mailing address:
  • Phone: 907-729-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

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