Organization
FAIRWAY CHILDREN'S MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACKYLN CHAN MD (OWNER)
(909) 630-8762
Entity
Organization
Contact information
Practice address
2707 E VALLEY BLVD STE 215, WEST COVINA, CA 91792-3197
(909) 594-3382
(626) 667-7633
Mailing address
888 BREA CANYON RD STE 330, DIAMOND BAR, CA 91789-3095
(909) 594-3382
(626) 667-7633
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1447544333
INDIVIDUAL TYPE 1 NPI
CA
01
—
A130711
CA MD STATE LICENSE #
CA
Enumeration date
07/13/2022
Last updated
04/23/2025
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