Healthcare Provider Details

I. General information

NPI: 1700510898
Provider Name (Legal Business Name): FAIRWAY CHILDREN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 E VALLEY BLVD STE 215
WEST COVINA CA
91792-3197
US

IV. Provider business mailing address

888 BREA CANYON RD STE 330
DIAMOND BAR CA
91789-3095
US

V. Phone/Fax

Practice location:
  • Phone: 909-594-3382
  • Fax: 626-667-7633
Mailing address:
  • Phone: 909-594-3382
  • Fax: 626-667-7633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JACKYLN CHAN
Title or Position: OWNER
Credential: MD
Phone: 909-630-8762