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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	20467	AK

General Provider Information

NPI Number	:	1639537640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHCENTRAL FOUNDATION

Provider Business Mailing Address
First Line	:	4501 DIPLOMACY DR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5919
Country	:	US
Telephone Number	:	907-729-4955
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 FLIGHT LINE ROAD
Second Line	:
City	:	PORT ALSWORTH
State	:	AK
Zip	:	99653
Country	:	US
Telephone Number	:	907-729-4955
Fax Number	:

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

Provider Enumeration Date	:	02/04/2016
Last Update Date	:	03/15/2016

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Directions to “SOUTHCENTRAL FOUNDATION ” Practice Location

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