Healthcare Provider Details

I. General information

NPI: 1912189424
Provider Name (Legal Business Name): JWCH INSTITUTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3634 MARTIN LUTHER KING JR BLVD
LYNWOOD CA
90262-2607
US

IV. Provider business mailing address

1910 W SUNSET BLVD STE 650
LOS ANGELES CA
90026-3281
US

V. Phone/Fax

Practice location:
  • Phone: 310-638-9025
  • Fax:
Mailing address:
  • Phone: 213-484-1186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA

VIII. Authorized Official

Name: ALVARO P. BALLESTEROS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 213-484-1186