Healthcare Provider Details

I. General information

NPI: 1164398608
Provider Name (Legal Business Name): MANUEL IVAN MARROQUIN CDM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 WILSHIRE BLVD
LOS ANGELES CA
90048-4920
US

IV. Provider business mailing address

12503 JERSEY AVE
NORWALK CA
90650-2321
US

V. Phone/Fax

Practice location:
  • Phone: 424-315-1042
  • Fax:
Mailing address:
  • Phone: 949-836-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: