Healthcare Provider Details

I. General information

NPI: 1457178055
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8243EAST STOCKTON BLVD SUITE A
SACRAMENTO CA
95828
US

IV. Provider business mailing address

1500 EXPO PKWY
SACRAMENTO CA
95815-4227
US

V. Phone/Fax

Practice location:
  • Phone: 916-737-5555
  • Fax:
Mailing address:
  • Phone: 916-469-4690
  • Fax: 916-880-5552

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 Number
License Number StateNULL

VIII. Authorized Official

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