1518401546 NPI number — FACULTY PHYSICIANS AND SURGEONS OF LLUSM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518401546 NPI number — FACULTY PHYSICIANS AND SURGEONS OF LLUSM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FACULTY PHYSICIANS AND SURGEONS OF LLUSM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518401546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FILE # 54701
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-4701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-4000
Provider Business Mailing Address Fax Number:
909-651-4352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 BROCKTON AVE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-4090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-558-6388
Provider Business Practice Location Address Fax Number:
909-651-4586
Provider Enumeration Date:
12/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PEVERINI
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-558-2480

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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