Provider Demographics
NPI:1558446179
Name:WELLSPACE HEALTH
Entity Type:Organization
Organization Name:WELLSPACE HEALTH
Other - Org Name:STRATEGIES FOR CHANGE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:A. JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTEUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:916-550-5444
Mailing Address - Street 1:777 12TH STREET
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814
Mailing Address - Country:US
Mailing Address - Phone:916-550-5444
Mailing Address - Fax:916-436-5527
Practice Address - Street 1:4343 WILLIAMSBOURGH DRIVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2006
Practice Address - Country:US
Practice Address - Phone:916-395-3552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA942600143251S00000X
251S00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA343425000Medicaid