Healthcare Provider Details

I. General information

NPI: 1104274596
Provider Name (Legal Business Name): JWCH INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15898 GALE AVE
HACIENDA HEIGHTS CA
91745-1601
US

IV. Provider business mailing address

5650 JILLSON ST
COMMERCE CA
90040-1482
US

V. Phone/Fax

Practice location:
  • Phone: 323-201-4516
  • Fax:
Mailing address:
  • Phone: 323-201-4516
  • Fax: 323-215-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALVARO P. BALLESTEROS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 323-201-4516