NPIMap

Organization Active NPI

Elica Health Centers

  • Federally Qualified Health Center (FQHC)
  • Sacramento, CA
National Provider Identifier
1093974065
Registry record updated Feb 18, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
ELICA HEALTH CENTERS
Practice address
3701 J St Ste 201
Sacramento, CA 95816-5542
Phone
(916) 454-2345
Fax
(916) 457-2667
NPI assigned
Jun 5, 2008
Last updated
Feb 18, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
ELICA HEALTH CENTERSAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 18, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tatyana Bak
Title
Ceo
Phone
(916) 569-8484

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Case Manager/Care CoordinatorGroup: 193200000X MULTI-SPECIALTY GROUP 171M00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

3701 J St Ste 201
Sacramento, CA 95816-5542

Mailing address

1860 Howe Ave Ste 440
Sacramento, CA 95825-1098
Phone (916) 569-8484

Other names 1

  • Elica Health Centers - Midtown Medical Centers Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090818000598 CA Part B Supplier - Clinic/Group Practice 4385706845 Receives reassigned benefits from 105 practitioners
15 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Sacramento, CA; West Sacramento, CA; North Highlands, CA
O20110502000718 CA Part A Provider - Federally Qualified Health Center (FQHC) 4385706845 Practice locations: Sacramento, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1093974065. Details of each certification follow.

Federally qualified health center certification: CCN 551093

Legal name
ELICA HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 2, 2011
Last certification
May 2, 2011
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Mar 6, 2002 in CA
Enrollment address
3701 J St
Ste 201
Sacramento, CA 95816-5542

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 15

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 15

National Provider Directory

National Provider Directory
Part of
Elica Health Centers

Locations

4815 Watt Ave
North Highlands, CA 95660

1750 Wright St
Ste 1
Sacramento, CA 95825

1750 Wright St
Ste A
Sacramento, CA 95825

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/15691/brand/4/csg/1/fhir/r4

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Vyacheslav Nikitin Individual Corporate OfficerBoard Member Jan 1, 2004
Corporate DirectorBoard Member Jan 1, 2004
Tatiana Foerster Individual Corporate OfficerBoard Member Jan 1, 2025
Evelina Khaykin Individual Corporate OfficerBoard Member Dec 8, 2020
Corporate DirectorBoard Member Dec 8, 2020
Tatyana Bak Individual Corporate OfficerCeo Oct 7, 2017
W-2 Managing EmployeeAd; Oct 7, 2017
Anna Rodriguez Individual Corporate OfficerBoard Member Apr 14, 2020
Corporate DirectorBoard Member Apr 14, 2020
Konstantin Bondar Individual Corporate OfficerBoard Member Jan 1, 2012
Corporate DirectorBoard Member Jan 1, 2012
Haylie Garrie Individual Corporate OfficerBoard Member Jan 1, 2025
Rakan Tayyeb Individual Corporate OfficerBoard Member Oct 25, 2017
Corporate DirectorBoard Member Oct 25, 2014
Jemal Gurdova Individual Corporate OfficerBoard Member Jan 1, 2025
Abrham Tekola Individual Corporate OfficerBoard Member Oct 25, 2017
Corporate DirectorBoard Member Oct 25, 2017
Anthony Ikeda Kolar Individual Corporate OfficerBoard Member Nov 1, 2013
Corporate DirectorBoard Member Nov 1, 2013
Natalia Efimova Individual Corporate OfficerBoard Member Jan 1, 2025
Tatyana Ford Individual Corporate OfficerBoard Member Jan 1, 2025

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1212624000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645142400000",
    "number": "1093974065",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1860 HOWE AVE STE 440",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958251098",
            "telephone_number": "916-569-8484",
            "fax_number": "916-256-2214"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3701 J ST STE 201",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958165542",
            "telephone_number": "916-454-2345",
            "fax_number": "916-457-2667"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELICA HEALTH CENTERS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ELICA HEALTH CENTERS",
        "enumeration_date": "2008-06-05",
        "last_updated": "2022-02-18",
        "certification_date": "2022-02-18",
        "status": "A",
        "authorized_official_last_name": "BAK",
        "authorized_official_first_name": "TATYANA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "916-569-8484"
    },
    "taxonomies": [
        {
            "code": "171M00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elica Health Centers - Midtown Medical Centers",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Sacramento, CA

Sources for this page

Verify at the official NPI Registry.