Provider Demographics
NPI:1588034169
Name:FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Entity Type:Organization
Organization Name:FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEVERINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-558-7448
Mailing Address - Street 1:FILE # 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:909-558-4000
Mailing Address - Fax:909-651-4586
Practice Address - Street 1:350 S EUCLID AVE
Practice Address - Street 2:UNIT C
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6665
Practice Address - Country:US
Practice Address - Phone:909-558-6388
Practice Address - Fax:909-651-4586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty