NPIMap

Organization Active NPI

Wellspace Health

  • Federally Qualified Health Center (FQHC)
  • Sacramento, CA
National Provider Identifier
1124257324
Registry record updated Mar 23, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
030000139 Issued in CA
Legal business name
WELLSPACE HEALTH
Practice address
3415 Martin Luther King Jr Blvd
Sacramento, CA 95817-3648
Phone
(916) 233-4910
Fax
(916) 731-8149
NPI assigned
Jul 8, 2009
Last updated
Mar 23, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Alasdair Jonathan Porteus, PHD
Title
Chief Executive Officer
Phone
(916) 737-5555

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Developmentally Disabled Services Day Training Agency 251C00000X NU
Federally Qualified Health Center (FQHC) 261QF0400X 030000139 CA Primary
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X NU
Home Delivered Meals 332U00000X NU
Personal Care Attendant 3747P1801X NU
Respite Care 385H00000X NU
Contractor 171W00000X NU
Case Manager/Care Coordinator 171M00000X NU
Supports Brokerage Agency 251X00000X NU

Addresses

Primary practice location

3415 Martin Luther King Jr Blvd
Sacramento, CA 95817-3648

Mailing address

1820 J St
Sacramento, CA 95811-3010
Phone (916) 550-5481

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070623000117 CA Part B Supplier - Clinic/Group Practice 8426157975 Receives reassigned benefits from 123 practitioners
23 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Sacramento, CA; Jackson, CA; Citrus Heights, CA; Folsom, CA; North Highlands, CA; Roseville, CA
O20100122000686 CA Part A Provider - Federally Qualified Health Center (FQHC) 8426157975 Practice locations: Sacramento, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124257324. Details of each certification follow.

Federally qualified health center certification: CCN 551021

Legal name
WELLSPACE HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 22, 2010
Last certification
Jan 22, 2010
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Feb 7, 1970 in CA
Enrollment address
3415 Martin Luther King Jr Blvd
Sacramento, CA 95817-3648

Other NPIs with the same Medicare PAC ID 16

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 16

Other NPIs on the same Medicare enrollment 23

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 23

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Brenda a Shipp Individual Corporate OfficerChief Operaions Officer Jun 9, 2014
W-2 Managing EmployeeChief Operations Officer Jun 9, 2014
Operational/Managerial ControlChief Operations Officer Jun 9, 2014
Ruth Pasillas Gonzales Individual Corporate DirectorBoard Director Jul 1, 2013
Lawrence Maas Individual Corporate DirectorBoard Director Jul 1, 2006
Lisa Stewart Individual Corporate DirectorBoard Director Jul 1, 2014
Kathy Walker Individual Contracted Managing EmployeeChief Financial Officer Mar 1, 2013
Corporate OfficerChief Financial Officer Mar 1, 2013
Operational/Managerial ControlChief Financial Officer Mar 1, 2013
James Tilton Individual Corporate DirectorBoard Vice President Jul 1, 2004
Jonathan a Porteus Individual Contracted Managing EmployeeChief Executive Officer Jan 1, 2011
Corporate OfficerChief Executive Officer Jan 1, 2011
W-2 Managing EmployeeChief Executive Officer Jan 1, 2011
Operational/Managerial ControlChief Executive Officer Jan 1, 2011
Ruzwa Cooper Individual Corporate DirectorBoard Director Jul 30, 2013
Jo Ann 'Jody' Gray Individual Corporate DirectorBoard Secretary Jul 1, 2014
Steven Hubbard Individual Corporate DirectorBoard Treasurer Jul 1, 2000
Wellspace Health Organization, Sacramento, CA Non-profit Operational/Managerial Control Jan 4, 2010
Darrell Lake Individual Corporate DirectorBoard Director Jul 1, 2013
Steven Olds Individual Corporate DirectorBoard President Jul 1, 2002

Owners & managing parties with NPI records 16

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 16

All facility ownership & control disclosures 10

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Wellspace HealthSacramento, CA, CCN 051142 Federally qualified health center Operational/Managerial Control Feb 7, 1970
Wellspace Health North Highlands Community Health CenterNorth Highlands, CA, CCN 551020 Federally qualified health center Operational/Managerial Control Nov 27, 2011
Wellspace HealthSacramento, CA, CCN 551022 Federally qualified health center Operational/Managerial Control May 17, 2010
Wellspace HealthRoseville, CA, CCN 751000 Federally qualified health center Operational/Managerial Control Mar 16, 2012
Wellspace Health Healthcare for Women Community Health CenterSacramento, CA, CCN 921070 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Feb 7, 1970
Wellspace HealthSacramento, CA, CCN 921843 Federally qualified health center Operational/Managerial Control Feb 7, 1970
Wellspace HealthSacramento, CA, CCN 921842 Federally qualified health center Operational/Managerial Control Feb 7, 1970
Wellspace HealthSacramento, CA, CCN 921841 Federally qualified health center Operational/Managerial Control Feb 7, 1970
Wellspace Health Sunrise CommunityCitrus Heights, CA, CCN 921844 Federally qualified health center Operational/Managerial Control Feb 7, 1970
Wellspace Health Sierra Garden 2Roseville, CA, CCN 921840 Federally qualified health center Operational/Managerial Control Feb 7, 1970

Owned or controlled facilities with NPI records 10

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 10

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 43

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 43

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1247011200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1647993600000",
    "number": "1124257324",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1820 J ST",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958113010",
            "telephone_number": "916-550-5481",
            "fax_number": "916-822-8974"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3415 MARTIN LUTHER KING JR BLVD",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958173648",
            "telephone_number": "916-233-4910",
            "fax_number": "916-731-8149"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSPACE HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-07-08",
        "last_updated": "2022-03-23",
        "certification_date": "2022-03-23",
        "status": "A",
        "authorized_official_last_name": "PORTEUS",
        "authorized_official_first_name": "ALASDAIR",
        "authorized_official_middle_name": "JONATHAN",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "916-737-5555",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "251C00000X",
            "taxonomy_group": "",
            "desc": "Day Training, Developmentally Disabled Services",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "030000139",
            "primary": true
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332U00000X",
            "taxonomy_group": "",
            "desc": "Home Delivered Meals",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3747P1801X",
            "taxonomy_group": "",
            "desc": "Technician, Personal Care Attendant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "385H00000X",
            "taxonomy_group": "",
            "desc": "Respite Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "171W00000X",
            "taxonomy_group": "",
            "desc": "Contractor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251X00000X",
            "taxonomy_group": "",
            "desc": "Supports Brokerage",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sacramento, CA

Sources for this page

Verify at the official NPI Registry.