Healthcare Provider Details

I. General information

NPI: 1225754955
Provider Name (Legal Business Name): CORONADO CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 W 18TH ST
PORTALES NM
88130-7097
US

IV. Provider business mailing address

1604 W 18TH ST
PORTALES NM
88130-7097
US

V. Phone/Fax

Practice location:
  • Phone: 575-359-4719
  • Fax:
Mailing address:
  • Phone: 575-359-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID GARETZ
Title or Position: CFO
Credential:
Phone: 323-987-5954