Healthcare Provider Details

I. General information

NPI: 1104433176
Provider Name (Legal Business Name): CORONA HEALTH SPECIALTY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 S MAIN ST STE 201
CORONA CA
92882-2536
US

IV. Provider business mailing address

1901 TOWN AND COUNTRY DR STE 104
NORCO CA
92860-3611
US

V. Phone/Fax

Practice location:
  • Phone: 951-734-4880
  • Fax:
Mailing address:
  • Phone: 951-808-6240
  • Fax: 951-738-9954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT G NELSON
Title or Position: PRESIDENT
Credential: MD
Phone: 951-808-6240