Healthcare Provider Details

I. General information

NPI: 1770361065
Provider Name (Legal Business Name): INTO THE LIGHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E REDLANDS BLVD STE 275
REDLANDS CA
92373-4721
US

IV. Provider business mailing address

101 E REDLANDS BLVD STE 200
REDLANDS CA
92373-4724
US

V. Phone/Fax

Practice location:
  • Phone: 855-984-1788
  • Fax: 909-335-2804
Mailing address:
  • Phone: 855-984-1788
  • 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: RONALD E HONN
Title or Position: PROGRAM ADMINISTRATOR
Credential: LAADC
Phone: 855-984-1788