1457895302 NPI number — ELICA HEALTH CENTERS

Table of content: (NPI 1457895302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457895302 NPI number — ELICA HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELICA HEALTH CENTERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ELICA HEALTH CENTERS- V STREET MEDICAL CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457895302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1860 HOWE AVE STE 440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-1098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-569-8484
Provider Business Mailing Address Fax Number:
916-256-2214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
923 V ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95818-1331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-454-2345
Provider Business Practice Location Address Fax Number:
916-890-3828
Provider Enumeration Date:
12/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BAK
Authorized Official First Name:
TATYANA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
916-569-8484

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CB101A . This is a "MEDICARE PART B" identifier . This identifiers is of the category "OTHER".




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