Healthcare Provider Details

I. General information

NPI: 1982523288
Provider Name (Legal Business Name): PONO PSYCHIATRY & WELLNESS A PROFESSIONAL NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 PEPPERWOOD AVE
LONG BEACH CA
90808-1070
US

IV. Provider business mailing address

4539 PEPPERWOOD AVE
LONG BEACH CA
90808-1070
US

V. Phone/Fax

Practice location:
  • Phone: 661-313-2166
  • Fax:
Mailing address:
  • Phone: 661-313-2166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VICMAR BURGONIO
Title or Position: PROVIDER
Credential:
Phone: 661-313-2166