Healthcare Provider Details

I. General information

NPI: 1780435628
Provider Name (Legal Business Name): COAST MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 10/18/2025
Certification Date: 10/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W BALL RD STE 4C
ANAHEIM CA
92804-5591
US

IV. Provider business mailing address

532 N MAGNOLIA AVE # 769
ANAHEIM CA
92801-4937
US

V. Phone/Fax

Practice location:
  • Phone: 626-429-0088
  • Fax:
Mailing address:
  • Phone: 714-683-1472
  • Fax: 714-683-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JACKSON TEA
Title or Position: VP/BOARD OF DIRECTOR
Credential:
Phone: 626-429-0088