Provider Demographics
NPI:1740587914
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:DR
Authorized Official - First Name:ALASDAIR
Authorized Official - Middle Name:'JONATHAN'
Authorized Official - Last Name:PORTEUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-737-5555
Mailing Address - Street 1:1820 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-3010
Mailing Address - Country:US
Mailing Address - Phone:916-550-5481
Mailing Address - Fax:916-822-8974
Practice Address - Street 1:3900 47TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824-2430
Practice Address - Country:US
Practice Address - Phone:916-313-8488
Practice Address - Fax:916-313-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551095Medicare Oscar/Certification