Healthcare Provider Details

I. General information

NPI: 1063849750
Provider Name (Legal Business Name): MARCELO JOSE ZURITA LMT #17191
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10459 NW LOST PARK DR
PORTLAND OR
97229-5024
US

IV. Provider business mailing address

10459 NW LOST PARK DR
PORTLAND OR
97229-5024
US

V. Phone/Fax

Practice location:
  • Phone: 503-644-0235
  • Fax: 503-644-0235
Mailing address:
  • Phone: 503-644-0235
  • Fax: 503-644-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT #17191
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: