Provider Demographics
NPI:1265643696
Name:SOUTHCENTRAL FOUNDATION OPT
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION OPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-729-1905
Mailing Address - Street 1:4341 TUDOR CENTRE DR
Mailing Address - Street 2:ATTN SHERRY REEDY
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5904
Mailing Address - Country:US
Mailing Address - Phone:907-729-3971
Mailing Address - Fax:907-729-1542
Practice Address - Street 1:4341 TUDOR CENTRE DR
Practice Address - Street 2:ATTN SHERRY REEDY
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5904
Practice Address - Country:US
Practice Address - Phone:907-729-3971
Practice Address - Fax:907-729-1542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20467282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL0670Medicaid
AKCL0670Medicaid