Provider Demographics
NPI:1417212903
Name:GOCORONA LLC
Entity Type:Organization
Organization Name:GOCORONA LLC
Other - Org Name:UNION MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-578-4815
Mailing Address - Street 1:304 S LEA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4562
Mailing Address - Country:US
Mailing Address - Phone:575-578-4815
Mailing Address - Fax:575-578-4814
Practice Address - Street 1:304 S LEA AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-4562
Practice Address - Country:US
Practice Address - Phone:575-578-4815
Practice Address - Fax:575-578-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0650208D00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11773537Medicaid