Basic Information
| Provider Information | |||||||||
| NPI: | 1104293141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JWCH INSTITUTE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MINI HOUSE RESIDENTIAL TREATMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5650 JILLSON ST | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238130200 | ||||||||
| FaxNumber: | 3238130207 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 E 52ND ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900114513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238130200 | ||||||||
| FaxNumber: | 3238130207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2015 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | VERA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3238130200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JWCH INSTITUTE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0800X | 190718AN | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care |
No ID Information.