Provider Demographics
NPI:1225754955
Name:CORONADO CARE CENTER LLC
Entity Type:Organization
Organization Name:CORONADO CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GARETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-987-5954
Mailing Address - Street 1:1604 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7097
Mailing Address - Country:US
Mailing Address - Phone:575-359-4719
Mailing Address - Fax:
Practice Address - Street 1:1604 W 18TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7097
Practice Address - Country:US
Practice Address - Phone:575-359-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility