Provider Demographics
NPI:1750052387
Name:SOUTHCENTRALFOUNDATION
Entity type:Organization
Organization Name:SOUTHCENTRALFOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONA
Authorized Official - Middle Name:
Authorized Official - Last Name:TETZLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-729-5083
Mailing Address - Street 1:7033 E TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1262
Mailing Address - Country:US
Mailing Address - Phone:907-729-5083
Mailing Address - Fax:907-729-5180
Practice Address - Street 1:3223 E PALMER WASILLA HWY STE 4
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7277
Practice Address - Country:US
Practice Address - Phone:907-729-6799
Practice Address - Fax:907-729-8607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty