Healthcare Provider Details

I. General information

NPI: 1699071753
Provider Name (Legal Business Name): FACULTY MEDICAL GROUP OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28078 BAXTER RD
MURRIETA CA
92563
US

IV. Provider business mailing address

FILE NO 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 951-290-6366
  • Fax: 951-290-6990
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA WOLTER
Title or Position: PROVIDER ENROLLMENT REP
Credential:
Phone: 909-558-3289