Healthcare Provider Details

I. General information

NPI: 1033361886
Provider Name (Legal Business Name): FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4244 RIVERWALK PKWY STE 100
RIVERSIDE CA
92505-3372
US

IV. Provider business mailing address

FILE # 54701
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2154
  • Fax:
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

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