Basic Information
| Provider Information | |||||||||
| NPI: | 1811455819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPACE HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPACE HEALTH DEL PASO HEIGHTS COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 12TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958141929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165505481 | ||||||||
| FaxNumber: | 9165203921 | ||||||||
| Practice Location | |||||||||
| Address1: | 3441 MARYSVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958384512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165637200 | ||||||||
| FaxNumber: | 9165637220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | PORTEUS | ||||||||
| AuthorizedOfficialFirstName: | ALASDAIR | ||||||||
| AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9163138413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD. | ||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 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.