Provider Demographics
NPI:1982097937
Name:INNER LIGHT HOUSE LLC
Entity Type:Organization
Organization Name:INNER LIGHT HOUSE LLC
Other - Org Name:BRENDA BRADSHAW CSONKA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW CSONKA
Authorized Official - Suffix:
Authorized Official - Credentials:MASSAGE THERAPIST
Authorized Official - Phone:352-494-7092
Mailing Address - Street 1:29 EASTBROOK CT
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:CA
Mailing Address - Zip Code:94517-1019
Mailing Address - Country:US
Mailing Address - Phone:352-494-7092
Mailing Address - Fax:
Practice Address - Street 1:325 N WIGET LN
Practice Address - Street 2:SUITE 130
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2435
Practice Address - Country:US
Practice Address - Phone:925-935-5425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNER LIGHT HOUSE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00024621225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty