Basic Information
| Provider Information | |||||||||
| NPI: | 1558788331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY PHYSICIANS AND SURGEONS OF LLUSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE # 54701 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
| FaxNumber: | 9096514586 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 E LATHAM AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925434342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516583134 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2014 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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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: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.