Healthcare Provider Details

I. General information

NPI: 1033295084
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 AUBURN BLVD SUITE E
SACRAMENTO CA
95841-4139
US

IV. Provider business mailing address

777 12TH STREET SUITE 250
SACRAMENTO CA
95814
US

V. Phone/Fax

Practice location:
  • Phone: 916-473-5764
  • Fax: 916-473-5766
Mailing address:
  • Phone: 916-550-5444
  • Fax: 916-436-5527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number942600143
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: A. JONATHAN PORTEUS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 916-550-5444