Provider Demographics
NPI:1295903094
Name:VONBERNUTH, POUNGSRI (LMT)
Entity type:Individual
Prefix:MS
First Name:POUNGSRI
Middle Name:
Last Name:VONBERNUTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E WINDHORST RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2524
Mailing Address - Country:US
Mailing Address - Phone:813-685-2315
Mailing Address - Fax:
Practice Address - Street 1:110 E WINDHORST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2524
Practice Address - Country:US
Practice Address - Phone:813-685-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM11331261Q00000X
FLMA13798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center