Healthcare Provider Details

I. General information

NPI: 1033712278
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 DNR RD
MCGRATH AK
99627
US

IV. Provider business mailing address

7033 E TUDOR RD
ANCHORAGE AK
99507-1262
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-4987
  • Fax: 907-729-8607
Mailing address:
  • Phone: 907-729-6580
  • Fax: 907-729-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JONA TETZLOFF
Title or Position: MANAGER OF REVENUE CYCLE
Credential:
Phone: 907-729-5083