Healthcare Provider Details

I. General information

NPI: 1275916736
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 FLORIN RD STE 16
SACRAMENTO CA
95823-1822
US

IV. Provider business mailing address

1820 J ST
SACRAMENTO CA
95811-3010
US

V. Phone/Fax

Practice location:
  • Phone: 916-325-5556
  • Fax:
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: DR. ALASDAIR 'JONATHAN' PORTEUS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 916-737-5555