Healthcare Provider Details

I. General information

NPI: 1184751794
Provider Name (Legal Business Name): FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 ROSECRANS AVE
EL SEGUNDO CA
90245-4747
US

IV. Provider business mailing address

54701 FILE NUMBER
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 800-242-1103
  • Fax:
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICARDO PEVERINI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-558-7448