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General NPI Number Information
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NPI Number | 1477056166
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Entity Type | Organization
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Legal Business Name | LIDO WELLNESS CENTER
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Dates
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Enumeration Date | 03/09/2018
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Last Update Date | 03/09/2018
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Provider Practice Location Address
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Address Line | 3404 VIA LIDO
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-3968
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Country | US
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Telephone | 949-633-2821
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Fax |
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Provider Business Mailing Address
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Address Line | 3419 VIA LIDO # 313
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-3908
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Country | US
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Telephone | 949-633-2821
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. COLLIN WEEDEN
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Credential |
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Telephone | 949-633-2821
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State | CA
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