Healthcare Provider Details

I. General information

NPI: 1679819007
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 MARTIN LUTHER KING JR. BLVD
SACRAMENTO CA
95817-3648
US

IV. Provider business mailing address

1820 J STREET
SACRAMENTO CA
95811-3010
US

V. Phone/Fax

Practice location:
  • Phone: 916-646-8000
  • Fax: 916-822-8974
Mailing address:
  • Phone: 916-550-5481
  • Fax: 916-822-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number550001135
License Number StateCA

VIII. Authorized Official

Name: DR. ALASDAIR JONATHAN PORTEUS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 916-737-5555