Provider Demographics
NPI:1356696553
Name:CORONADO SURGICAL LLC
Entity type:Organization
Organization Name:CORONADO SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CROVETTI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:702-990-2290
Mailing Address - Street 1:2779 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4184
Mailing Address - Country:US
Mailing Address - Phone:702-932-8370
Mailing Address - Fax:702-932-8377
Practice Address - Street 1:2779 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4184
Practice Address - Country:US
Practice Address - Phone:702-589-4975
Practice Address - Fax:702-589-4978
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORONADO SURGICAL RECOVERY SUITES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-13
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20111055516282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital