Healthcare Provider Details

I. General information

NPI: 1861942849
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 WATT AVE #2
NORTH HIGHLANDS CA
95660-4294
US

IV. Provider business mailing address

1820 J ST
SACRAMENTO CA
95811-3010
US

V. Phone/Fax

Practice location:
  • Phone: 916-679-3925
  • Fax: 916-679-3928
Mailing address:
  • Phone: 916-550-5481
  • Fax: 916-822-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MISS JESSICA GOMEZ
Title or Position: MHA-I
Credential:
Phone: 916-679-3925