Healthcare Provider Details

I. General information

NPI: 1003469719
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KNIK GOOSE BAY RD
WASILLA AK
99654-8083
US

IV. Provider business mailing address

PO BOX 35198
SEATTLE WA
98124-5198
US

V. Phone/Fax

Practice location:
  • Phone: 907-631-7800
  • 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

VII. Legacy identifiers

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

# 1
Identifier1696887
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: RONALD LEE OLSON
Title or Position: EXECUTIVE VICE PRESIDENT OF FINANCE
Credential:
Phone: 907-729-4939