Provider Demographics
NPI:1114480167
Name:SOUTHCENTRAL FOUNDATION
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION
Other - Org Name:DENTAL- PORT ALSWORTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-729-4939
Mailing Address - Street 1:PO BOX 35151
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 FLIGHT LINE RD
Practice Address - Street 2:
Practice Address - City:PORT ALSWORTH
Practice Address - State:AK
Practice Address - Zip Code:99653-9801
Practice Address - Country:US
Practice Address - Phone:907-781-2256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHCENTRAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1695503Medicaid