Healthcare Provider Details

I. General information

NPI: 1902700180
Provider Name (Legal Business Name): SOUTH COAST WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KALMUS DR STE A104
COSTA MESA CA
92626-5900
US

IV. Provider business mailing address

151 KALMUS DR STE A104
COSTA MESA CA
92626-5900
US

V. Phone/Fax

Practice location:
  • Phone: 949-220-0850
  • Fax:
Mailing address:
  • Phone: 949-220-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMY LYNN ELLSWORTH
Title or Position: OWNER/CEO
Credential: RDN
Phone: 949-220-0850