MEDICARE: WELLSPACE HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1295293330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSPACE HEALTH

Provider Business Mailing Address
First Line	:	777 12TH ST STE 250
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95814-1929
Country	:	US
Telephone Number	:	916-550-5481
Fax Number	:	916-520-3921

Provider Business Practice Location Address
First Line	:	2727 W CAPITOL AVE
Second Line	:
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-2220
Country	:	US
Telephone Number	:	916-371-2275
Fax Number	:	916-371-8649

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. ALASDAIR JONATHAN PORTEUS
Credential	:	PHD.
Telephone Number	:	916-313-8413

Provider Enumeration Date	:	03/07/2019
Last Update Date	:	03/28/2019

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