Provider Demographics
NPI:1124257324
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:MR
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:916-737-5555
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 1:3415 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-3648
Practice Address - Country:US
Practice Address - Phone:916-233-4910
Practice Address - Fax:916-731-8149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 251C00000X, 251X00000X, 261QR0405X, 171M00000X, 332U00000X, 3747P1801X, 385H00000X
CA030000139261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No251X00000XAgenciesSupports BrokerageGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No332U00000XSuppliersHome Delivered Meals
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551021Medicare Oscar/Certification