Healthcare Provider Details

I. General information

NPI: 1710610324
Provider Name (Legal Business Name): JWCH INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 SAN JULIAN ST
LOS ANGELES CA
90014-2412
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: 323-215-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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