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General NPI Number Information
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NPI Number | 1427355619
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Entity Type | Organization
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Legal Business Name | FACULTY PHYSICIANS AND SURGEONS OF LLUSM
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Dates
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Enumeration Date | 02/24/2011
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Last Update Date | 02/24/2011
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Provider Practice Location Address
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Address Line | 28078 BAXTER RD
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City | MURRIETA
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State | CA
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Zip | 92563
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Country | US
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Telephone | 951-290-6366
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Fax |
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Provider Business Mailing Address
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Address Line | 11165 MOUNTAIN VIEW AVE STE 228
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City | LOMA LINDA
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State | CA
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Zip | 92354-3866
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Country | US
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Telephone | 909-558-3111
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Fax |
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Authorized Official
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Title or Position | PROVIDER ENROLLMENT REPRESENTATIVE
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Name | MS. LISA WOLTER
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Credential |
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Telephone | 909-558-3289
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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