Healthcare Provider Details

I. General information

NPI: 1295293330
Provider Name (Legal Business Name): WELLSPACE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 W CAPITOL AVE
WEST SACRAMENTO CA
95691-2220
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 916-371-2275
  • Fax: 916-371-8649
Mailing address:
  • Phone: 916-550-5481
  • Fax: 916-520-3921

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: 916-313-8413