Healthcare Provider Details

I. General information

NPI: 1821357492
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8231 E STOCKTON BLVD SUITE C
SACRAMENTO CA
95828-8202
US

IV. Provider business mailing address

1820 J ST
SACRAMENTO CA
95811-3010
US

V. Phone/Fax

Practice location:
  • Phone: 916-737-5573
  • Fax: 916-405-6342
Mailing address:
  • Phone: 916-550-5481
  • Fax: 916-822-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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