Healthcare Provider Details

I. General information

NPI: 1912004920
Provider Name (Legal Business Name): FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28078 BAXTER RD
MURRIETA CA
92563-1400
US

IV. Provider business mailing address

54701 FILE NUMBER
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RICARDO PEVERINI
Title or Position: PRESIDENT
Credential: MD
Phone: 909-558-7448