Basic Information
| Provider Information | |||||||||
| NPI: | 1760739601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHCENTRAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 S KNIK GOOSE BAY RD | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996548083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076317800 | ||||||||
| FaxNumber: | 9076317619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S KNIK GOOSE BAY RD | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996548083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076317800 | ||||||||
| FaxNumber: | 9076317619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9077294939 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | 20467 | AK | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
No ID Information.