MEDICARE: SOUTHCENTRAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist
2	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376215475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHCENTRAL FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 35151
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98124-5151
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3606 RHONE CIR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5053
Country	:	US
Telephone Number	:	907-729-2000
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT FINANCE
Name	:	RONALD LEE OLSON
Credential	:
Telephone Number	:	907-729-4939

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	09/01/2023

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Directions to “SOUTHCENTRAL FOUNDATION ” Practice Location

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