NPIMap

Organization Active NPI

Elica Health Centers

  • Federally Qualified Health Center (FQHC)
  • West Sacramento, CA
National Provider Identifier
1760013494
Registry record updated Mar 8, 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
1276 Halyard Dr
West Sacramento, CA 95691-3412
Phone
(916) 454-2345
NPI assigned
Jan 31, 2020
Last updated
Mar 8, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
ELICA HEALTH CENTERSAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 8, 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

1276 Halyard Dr
West Sacramento, CA 95691-3412

Mailing address

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

Other names 1

  • ELICA HEALTH CENTERS - HEALTH ON WHEELS 3 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
O20190717002456 CA Part A Provider - Federally Qualified Health Center (FQHC) 4385706845 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: West Sacramento, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760013494. Details of each certification follow.

Federally qualified health center certification: CCN 921159

Legal name
ELICA HEALTH CENTERS
Doing business as
ELICA HEALTH CENTERS-HALYARD MEDICAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 2, 2019
Last certification
Apr 2, 2019
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 6, 2002 in CA
Enrollment address
1276 Halyard Dr
West Sacramento, CA 95691-3412

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

1860 Howe Ave
Ste 440
Sacramento, CA 95825

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 DirectorBoard Member Jan 1, 2004
Tatiana Foerster Individual Corporate DirectorBoard Member Jan 1, 2025
Evelina Khaykin Individual Corporate DirectorBoard Member Jan 1, 2025
Tatyana Bak Individual Corporate Director Oct 7, 2017
W-2 Managing Employee Oct 7, 2017
Operational/Managerial ControlCeo Oct 7, 2017 100%
Anna Rodriguez Individual Corporate DirectorBoard Member Jan 1, 2025
Konstantin Bondar Individual Corporate DirectorBoard Member Jan 1, 2013
Haylie Garrie Individual Corporate DirectorBoard Member Jan 1, 2025
Rakan Tayyeb Individual Corporate DirectorBoard Member Oct 15, 2017
Jemal Gurdova Individual Corporate DirectorBoard Member Jan 1, 2025
Abrham Tekola Individual Corporate DirectorBoard Member Oct 25, 2017
Anthony Ikeda Kolar Individual Corporate DirectorBoard Member Nov 1, 2013
Natalia Efimova Individual Corporate DirectorBoard Member Jan 1, 2025
Tatyana Ford Individual Corporate DirectorBoard 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 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1580428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646697600000",
    "number": "1760013494",
    "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": "916-550-5003"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1276 HALYARD DR",
            "city": "WEST SACRAMENTO",
            "state": "CA",
            "postal_code": "956913412",
            "telephone_number": "916-454-2345"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELICA HEALTH CENTERS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ELICA HEALTH CENTERS",
        "enumeration_date": "2020-01-31",
        "last_updated": "2022-03-08",
        "certification_date": "2022-03-08",
        "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 - HEALTH ON WHEELS 3",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "ELICA HEALTH CENTERS - HEALTH ON WHEELS 3",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in West Sacramento, CA

Sources for this page

Verify at the official NPI Registry.