Healthcare Provider Details

I. General information

NPI: 1700771995
Provider Name (Legal Business Name): CORONADO WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N MAIN ST STE 11
SPRINGVILLE UT
84663-4016
US

IV. Provider business mailing address

3507 N UNIVERSITY AVE STE 225
PROVO UT
84604-6635
US

V. Phone/Fax

Practice location:
  • Phone: 801-960-9355
  • Fax:
Mailing address:
  • Phone: 801-960-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MONICA BLUME
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 801-960-9355