=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700510898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRWAY CHILDREN'S MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2022
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2707 E VALLEY BLVD STE 215
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91792-3197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-594-3382
-----------------------------------------------------
Fax | 626-667-7633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 BREA CANYON RD STE 330
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-3095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-594-3382
-----------------------------------------------------
Fax | 626-667-7633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACKYLN CHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-630-8762
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------