Provider Demographics
NPI:1043023070
Name:MIRAVITE, MARCO-LUIS MORENO (DC)
Entity type:Individual
Prefix:DR
First Name:MARCO-LUIS
Middle Name:MORENO
Last Name:MIRAVITE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 N EL MOLINO AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-5601
Mailing Address - Country:US
Mailing Address - Phone:626-792-1221
Mailing Address - Fax:
Practice Address - Street 1:131 N EL MOLINO AVE STE 180
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5601
Practice Address - Country:US
Practice Address - Phone:626-792-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC37173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor