Basic Information
| Provider Information | |||||||||
| NPI: | 1679754634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY PHYSICIANS AND SURGEONS OF LLUSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 54701 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 WEST AVE Q | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | PEVERINI | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDERN | ||||||||
| AuthorizedOfficialTelephone: | 9095587448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.