Basic Information
Provider Information | |||||||||
NPI: | 1225335581 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLSPACE HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1820 J ST | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958113010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9165505481 | ||||||||
FaxNumber: | 9168228974 | ||||||||
Practice Location | |||||||||
Address1: | 5321 STOCKTON BLVD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958205411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167064650 | ||||||||
FaxNumber: | 9164056551 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2011 | ||||||||
LastUpdateDate: | 03/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PORTEUS | ||||||||
AuthorizedOfficialFirstName: | ALASDAIR | ||||||||
AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9167375555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: | 03/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QR0405X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 171W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Contractor |   | 251C00000X |   |   | N |   | Agencies | Day Training, Developmentally Disabled Services |   | 251X00000X |   |   | N |   | Agencies | Supports Brokerage |   | 332U00000X |   |   | N |   | Suppliers | Home Delivered Meals |   | 3747P1801X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant | 385H00000X |   |   | N |   | Respite Care Facility | Respite Care |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.