Provider Demographics
NPI:1639537640
Name:SOUTHCENTRAL FOUNDATION
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION
Other - Org Name:PORT ALSWORTH BSD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP 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 1:4501 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5919
Mailing Address - Country:US
Mailing Address - Phone:907-729-4955
Mailing Address - Fax:
Practice Address - Street 1:1 FLIGHT LINE ROAD
Practice Address - Street 2:
Practice Address - City:PORT ALSWORTH
Practice Address - State:AK
Practice Address - Zip Code:99653
Practice Address - Country:US
Practice Address - Phone:907-729-4955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20467261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)