Basic Information
| Provider Information | |||||||||
| NPI: | 1558603555 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPACE HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 J ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958113010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165505481 | ||||||||
| FaxNumber: | 9168228974 | ||||||||
| Practice Location | |||||||||
| Address1: | 3737 MARCONI AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958215303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165698660 | ||||||||
| FaxNumber: | 9169780310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | PORTEUS | ||||||||
| AuthorizedOfficialFirstName: | ALASDAIR | ||||||||
| AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9165505444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.