Provider Demographics
NPI:1538660865
Name:WELLSPACE HEALTH
Entity Type:Organization
Organization Name:WELLSPACE HEALTH
Other - Org Name:WELLSPACE HEALTH SIERRA GARDENS COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
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:916-550-5444
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:916-550-5444
Mailing Address - Fax:916-436-5527
Practice Address - Street 1:1101 SMITH LN
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4103
Practice Address - Country:US
Practice Address - Phone:916-407-2222
Practice Address - Fax:916-985-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)