Healthcare Provider Details

I. General information

NPI: 1104210608
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 65TH ST SUITE C
SACRAMENTO CA
95820-2057
US

IV. Provider business mailing address

1820 J STREET
SACRAMENTO CA
95811
US

V. Phone/Fax

Practice location:
  • Phone: 916-737-5555
  • Fax: 916-444-5620
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 StateCA

VIII. Authorized Official

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