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General NPI Number Information
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NPI Number | 1417212903
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Entity Type | Organization
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Legal Business Name | GOCORONA LLC
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Dates
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Enumeration Date | 07/10/2012
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Last Update Date | 11/20/2018
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Provider Practice Location Address
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Address Line | 304 S LEA AVE
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City | ROSWELL
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State | NM
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Zip | 88203-4562
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Country | US
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Telephone | 575-578-4815
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Fax | 575-578-4814
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Provider Business Mailing Address
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Address Line | 304 S LEA AVE
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City | ROSWELL
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State | NM
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Zip | 88203-4562
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Country | US
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Telephone | 575-578-4815
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Fax | 575-578-4814
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. GONZALO CORONA
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Credential | M.D
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Telephone | 575-578-4815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | MD2007-0650
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MD2007-0650
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License Number State | NM
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