Healthcare Provider Details

I. General information

NPI: 1982356283
Provider Name (Legal Business Name): PON TINGSUK PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 OLD MAMMOTH RD
MAMMOTH LAKES CA
93546-6359
US

IV. Provider business mailing address

PO BOX 130
MAMMOTH LAKES CA
93546-0130
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-0031
  • Fax:
Mailing address:
  • Phone: 760-934-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number180065956
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: