Specialty |
Taxonomy Code | Specialty Code | Provider Type | |
Dental |
261QD0000X | |||
Dental Therapist |
125J00000X | |||
General Practice |
1223G0001X |
| NPI # | 1750961918 |
||||
| LBN Legal business name | SOUTHCENTRAL FOUNDATION | ||||
| Authorized official | RONALD OLSON - (EXECUTIVE VICE PRESIDENT FINANCE) | ||||
| Entity | Organization | ||||
| Organization subpart 1 | Yes | ||||
| Enumeration date | 04/12/2021 | ||||
| Last updated | 09/15/2023 - About 3 years ago | ||||
| Identifiers |
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