Healthcare Provider Details

I. General information

NPI: 1831596311
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 POLOVINA TURNPIKE
ST PAUL AK
99660
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 907-546-2310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

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