Healthcare Provider Details

I. General information

NPI: 1316599640
Provider Name (Legal Business Name): FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N BROADWAY
SANTA ANA CA
92706-2607
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-3636
  • Fax:
Mailing address:
  • Phone: 909-651-4352
  • Fax: 909-651-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080T0004X
TaxonomyPediatric Transplant Hepatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State

VIII. Authorized Official

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