Basic Information
| Provider Information | |||||||||
| NPI: | 1265059182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELICA HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ELICA HEALTH CENTERS - CADILLAC DRIVE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 HOWE AVE STE 440 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958251098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165698484 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 77 CADILLAC DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958258337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164542345 | ||||||||
| FaxNumber: | 9168903828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2020 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAK | ||||||||
| AuthorizedOfficialFirstName: | TATYANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9165698484 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELICA HEALTH CENTERS | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.