Healthcare Provider Details

I. General information

NPI: 1225338007
Provider Name (Legal Business Name): CHANWELL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 S PARK VICTORIA DR
MILPITAS CA
95035-6996
US

IV. Provider business mailing address

1289 S PARK VICTORIA DR
MILPITAS CA
95035-6996
US

V. Phone/Fax

Practice location:
  • Phone: 408-586-8866
  • Fax:
Mailing address:
  • Phone: 408-586-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ESTRELLITA LUA CHAN
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 408-586-8866