Provider Demographics
NPI:1922405406
Name:SOUTHCENTRAL FOUNDATION
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION
Other - Org Name:TRIBAL- ST. PAUL COMMUNITY HEALTH CENTER
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 35198
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5198
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 POLOVINA TURNPIKE
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:AK
Practice Address - Zip Code:99660
Practice Address - Country:US
Practice Address - Phone:907-546-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHCENTRAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-26
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20467261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1627061Medicaid