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
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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