Healthcare Provider Details

I. General information

NPI: 1669130738
Provider Name (Legal Business Name): INTO THE LIGHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E REDLANDS BLVD STE 170E
REDLANDS CA
92373-4700
US

IV. Provider business mailing address

101 E REDLANDS BLVD STE 170E
REDLANDS CA
92373-4700
US

V. Phone/Fax

Practice location:
  • Phone: 909-233-5634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS BEETS
Title or Position: BILLING DIRECTOR
Credential:
Phone: 949-933-1931