Healthcare Provider Details

I. General information

NPI: 1275191926
Provider Name (Legal Business Name): FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207ZI0100X
TaxonomyImmunopathology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code207ZP0104X
TaxonomyChemical Pathology Physician
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 15
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICARDO PEVERINI
Title or Position: PRESIDENT
Credential: MD
Phone: 909-651-5582