Provider Demographics
NPI:1063849750
Name:ZURITA, MARCELO JOSE (LMT #17191)
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:JOSE
Last Name:ZURITA
Suffix:
Gender:M
Credentials:LMT #17191
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10459 NW LOST PARK DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5024
Mailing Address - Country:US
Mailing Address - Phone:503-644-0235
Mailing Address - Fax:503-644-0235
Practice Address - Street 1:10459 NW LOST PARK DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5024
Practice Address - Country:US
Practice Address - Phone:503-644-0235
Practice Address - Fax:503-644-0235
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT #17191225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist