Provider Demographics
NPI:1669638227
Name:SOUTHCENTRALFOUNDATION
Entity Type:Organization
Organization Name:SOUTHCENTRALFOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRSIDENT MEDICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-729-4955
Mailing Address - Street 1:4320 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5925
Mailing Address - Country:US
Mailing Address - Phone:907-729-4955
Mailing Address - Fax:
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
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:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10662261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK10662OtherSTATE OF ALASKA REGISTERED NURSE