Basic Information
| Provider Information | |||||||||
| NPI: | 1295829109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JWCH INSTITUTE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BELL GARDENS COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5650 JILLSON ST | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232014516 | ||||||||
| FaxNumber: | 3232150170 | ||||||||
| Practice Location | |||||||||
| Address1: | 6912 AJAX AVE | ||||||||
| Address2: | |||||||||
| City: | BELL GARDENS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902014057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235625813 | ||||||||
| FaxNumber: | 3233261146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALLESTEROS | ||||||||
| AuthorizedOfficialFirstName: | ALVARO | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3232014516 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 251X00000X | N | Agencies | Supports Brokerage | 261QF0400X | 550000019 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC71083F | 05 | CA | MEDICAID |