Healthcare Provider Details

I. General information

NPI: 1548388309
Provider Name (Legal Business Name): THOMAS DALE PONTIUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 ELM AVE
LONG BEACH CA
90802-2426
US

IV. Provider business mailing address

3021 SOFTWIND WAY
TORRANCE CA
90505-7129
US

V. Phone/Fax

Practice location:
  • Phone: 562-437-6717
  • Fax:
Mailing address:
  • Phone: 310-326-7726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number528060
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number528060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: