Healthcare Provider Details

I. General information

NPI: 1295781219
Provider Name (Legal Business Name): FACULTY MEDICAL GROUP OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25865 BARTON RD STE 101
LOMA LINDA CA
92354-3895
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-3636
  • Fax:
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: RICARDO PEVERINI
Title or Position: PRESIDENT FACULTY MEDICAL GROUP OF
Credential: MD
Phone: 909-558-7448