Provider Demographics
NPI:1063063600
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 JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTEUS PHD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-313-9413
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:916-469-4698
Mailing Address - Fax:916-313-8490
Practice Address - Street 1:151 N SUNRISE AVE STE 1309
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2933
Practice Address - Country:US
Practice Address - Phone:916-469-4698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)