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General NPI Number Information
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NPI Number | 1003967753
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Entity Type | Organization
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Legal Business Name | SOUTH CENTRAL FAMILY PRACTICE CLINIC PC
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 05/18/2018
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Provider Practice Location Address
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Address Line | 161 N BINKLEY ST SUITE 101
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City | SOLDOTNA
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State | AK
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Zip | 99669
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Country | US
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Telephone | 907-260-7784
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Fax | 907-260-7738
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Provider Business Mailing Address
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Address Line | PO BOX 1249
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City | SOLDOTNA
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State | AK
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Zip | 99669-1249
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Country | US
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Telephone | 907-260-7784
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Fax | 907-260-7738
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GLADYS J BAILON
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Credential | M.D.
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Telephone | 907-260-7784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 901044
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License Number State | AK
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