Provider Demographics
NPI:1477056166
Name:LIDO WELLNESS CENTER
Entity Type:Organization
Organization Name:LIDO WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-633-2821
Mailing Address - Street 1:3419 VIA LIDO # 313
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3908
Mailing Address - Country:US
Mailing Address - Phone:949-633-2821
Mailing Address - Fax:
Practice Address - Street 1:3404 VIA LIDO
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3968
Practice Address - Country:US
Practice Address - Phone:949-633-2821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health