Healthcare Provider Details

I. General information

NPI: 1417212903
Provider Name (Legal Business Name): GOCORONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S LEA AVE
ROSWELL NM
88203-4562
US

IV. Provider business mailing address

304 S LEA AVE
ROSWELL NM
88203-4562
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-4815
  • Fax: 575-578-4814
Mailing address:
  • Phone: 575-578-4815
  • Fax: 575-578-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD2007-0650
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD2007-0650
License Number StateNM

VIII. Authorized Official

Name: DR. GONZALO CORONA
Title or Position: DIRECTOR
Credential: M.D
Phone: 575-578-4815