Provider Demographics
NPI:1770245342
Name:DOKTHONGHOM, PORNSUDA
Entity Type:Individual
Prefix:
First Name:PORNSUDA
Middle Name:
Last Name:DOKTHONGHOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10326 ALMAYO AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-5213
Mailing Address - Country:US
Mailing Address - Phone:916-847-9429
Mailing Address - Fax:
Practice Address - Street 1:13456 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5626
Practice Address - Country:US
Practice Address - Phone:916-847-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83900225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist