Basic Information
| Provider Information | |||||||||
| NPI: | 1912189424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JWCH INSTITUTE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 W SUNSET BLVD | ||||||||
| Address2: | STE 650 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900263281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134841186 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3634 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902622607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106389025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2007 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | BALLESTEROS | ||||||||
| AuthorizedOfficialFirstName: | ALVARO | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2134841186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QC1500X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261Q00000X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | EAP70521F | 05 | CA | MEDICAID |