MEDICARE: GOCORONA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	MD2007-0650	NM
2	261QP2300X	Primary Care Clinic/Center	MD2007-0650	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417212903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOCORONA LLC

Provider Business Mailing Address
First Line	:	304 S LEA AVE
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88203-4562
Country	:	US
Telephone Number	:	575-578-4815
Fax Number	:	575-578-4814

Provider Business Practice Location Address
First Line	:	304 S LEA AVE
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88203-4562
Country	:	US
Telephone Number	:	575-578-4815
Fax Number	:	575-578-4814

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. GONZALO CORONA
Credential	:	M.D
Telephone Number	:	575-578-4815

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	11/20/2018

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Directions to “GOCORONA LLC ” Practice Location

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