Basic Information
| Provider Information | |||||||||
| NPI: | 1457680530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY PHYSICIANS AND SURGEONS OF LLUSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE # 54701 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12021 JACARANDA AVE. | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923454956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582848 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2009 | ||||||||
| LastUpdateDate: | 12/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | PEVERINI | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9095587448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.