Healthcare Provider Details

I. General information

NPI: 1154947711
Provider Name (Legal Business Name): ELICA HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6339 MACK RD
SACRAMENTO CA
95823-4655
US

IV. Provider business mailing address

1860 HOWE AVE STE 440
SACRAMENTO CA
95825-1098
US

V. Phone/Fax

Practice location:
  • Phone: 916-454-2345
  • Fax: 916-890-3828
Mailing address:
  • Phone: 916-569-8484
  • Fax: 916-890-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. TATYANA BAK
Title or Position: CEO
Credential:
Phone: 916-569-8484