Provider Demographics
NPI:1225550874
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:
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:916-313-8413
Mailing Address - Street 1:777 12TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-1929
Mailing Address - Country:US
Mailing Address - Phone:916-550-5481
Mailing Address - Fax:
Practice Address - Street 1:11333 PROSPECT DRIVE
Practice Address - Street 2:
Practice Address - City:MARTELL
Practice Address - State:CA
Practice Address - Zip Code:95645-9998
Practice Address - Country:US
Practice Address - Phone:209-268-0560
Practice Address - Fax:209-214-6946
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSPACE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-14
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171W00000X, 251C00000X, 251X00000X, 261QR0405X, 332U00000X, 3747P1801X, 385H00000X
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No251X00000XAgenciesSupports Brokerage
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No332U00000XSuppliersHome Delivered MealsGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care