Healthcare Provider Details

I. General information

NPI: 1760812192
Provider Name (Legal Business Name): FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E CAROLINE ST STE A, B, G
SAN BERNARDINO CA
92408-3747
US

IV. Provider business mailing address

FILE # 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-835-1810
  • Fax: 909-651-4586
Mailing address:
  • Phone: 909-558-3111
  • Fax: 909-651-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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