Healthcare Provider Details

I. General information

NPI: 1962312579
Provider Name (Legal Business Name): WYLDE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16520 BAKE PKWY STE 105
IRVINE CA
92618-4688
US

IV. Provider business mailing address

668 N COAST HWY # 1258
LAGUNA BEACH CA
92651-1513
US

V. Phone/Fax

Practice location:
  • Phone: 949-280-4222
  • Fax:
Mailing address:
  • Phone: 949-280-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SELDON J WIGGINS
Title or Position: OWNER
Credential:
Phone: 949-280-4222