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General NPI Number Information
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NPI Number | 1114480167
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Entity Type | Organization
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Legal Business Name | SOUTHCENTRAL FOUNDATION
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Dates
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Enumeration Date | 04/08/2019
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Last Update Date | 08/31/2023
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Provider Practice Location Address
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Address Line | 1 FLIGHT LINE RD
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City | PORT ALSWORTH
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State | AK
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Zip | 99653-9801
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Country | US
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Telephone | 907-781-2256
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 35151
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City | SEATTLE
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State | WA
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Zip | 98124-5151
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT FINANCE
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Name | RONALD LEE OLSON
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Credential |
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Telephone | 907-729-4939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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