Healthcare Provider Details

I. General information

NPI: 1043886369
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 E PALMER WASILLA HWY
WASILLA AK
99654-7277
US

IV. Provider business mailing address

PO BOX 35198
SEATTLE WA
98124-5198
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-6300
  • 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
Identifier1724999
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

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