Basic Information
| Provider Information | |||||||||
| NPI: | 1790419059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELICA HEALTH CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 HOWE AVE STE 440 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958251098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165698484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 GLENDALE LN | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958252431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164542345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAK | ||||||||
| AuthorizedOfficialFirstName: | TATYANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9165698484 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELICA HEALTH CENTERS | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.