Healthcare Provider Details

I. General information

NPI: 1962149864
Provider Name (Legal Business Name): WELLSPACE NEXUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 12TH ST STE 250
SACRAMENTO CA
95814-1929
US

IV. Provider business mailing address

777 12TH ST STE 250
SACRAMENTO CA
95814-1929
US

V. Phone/Fax

Practice location:
  • Phone: 916-737-5555
  • Fax:
Mailing address:
  • Phone: 916-737-5577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JONATHAN PORTEUS
Title or Position: CEO
Credential: PHD
Phone: 916-737-5577