Provider Demographics
NPI:1912189424
Name:JWCH INSTITUTE, INC.
Entity Type:Organization
Organization Name:JWCH INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALVARO
Authorized Official - Middle Name:P
Authorized Official - Last Name:BALLESTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-484-1186
Mailing Address - Street 1:1910 W SUNSET BLVD
Mailing Address - Street 2:STE 650
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-3281
Mailing Address - Country:US
Mailing Address - Phone:213-484-1186
Mailing Address - Fax:
Practice Address - Street 1:3634 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2607
Practice Address - Country:US
Practice Address - Phone:310-638-9025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X, 261QC1500X, 261QC1500X, 261QF0400X, 261QF0400X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70521FMedicaid