Provider Demographics
NPI:1790419059
Name:ELICA HEALTH CENTERS
Entity Type:Organization
Organization Name:ELICA HEALTH CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-569-8484
Mailing Address - Street 1:1860 HOWE AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1098
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:
Practice Address - Street 1:2400 GLENDALE LN
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2431
Practice Address - Country:US
Practice Address - Phone:916-454-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELICA HEALTH CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)