Healthcare Provider Details

I. General information

NPI: 1356696553
Provider Name (Legal Business Name): CORONADO SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2779 W HORIZON RIDGE PKWY SUITE 130
HENDERSON NV
89052-4184
US

IV. Provider business mailing address

2779 W HORIZON RIDGE PKWY SUITE 130
HENDERSON NV
89052-4184
US

V. Phone/Fax

Practice location:
  • Phone: 702-589-4975
  • Fax: 702-589-4978
Mailing address:
  • Phone: 702-932-8370
  • Fax: 702-932-8377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License NumberNV20111055516
License Number StateNV

VIII. Authorized Official

Name: DR. MICHAEL JAMES CROVETTI JR.
Title or Position: MANAGING MEMBER
Credential: D.O.
Phone: 702-990-2290