Provider Demographics
NPI:1104210608
Name:WELLSPACE HEALTH
Entity Type:Organization
Organization Name:WELLSPACE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALASDAIR
Authorized Official - Middle Name:JONATHAN
Authorized Official - Last Name:PORTEUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:916-737-5555
Mailing Address - Street 1:1820 J STREET
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811
Mailing Address - Country:US
Mailing Address - Phone:916-550-5481
Mailing Address - Fax:916-822-8974
Practice Address - Street 1:3535 65TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-2057
Practice Address - Country:US
Practice Address - Phone:916-737-5555
Practice Address - Fax:916-444-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)