Healthcare Provider Details

I. General information

NPI: 1437013414
Provider Name (Legal Business Name): COASTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10840 WARNER AVE STE 102A
FOUNTAIN VALLEY CA
92708-3847
US

IV. Provider business mailing address

10840 WARNER AVE STE 102A
FOUNTAIN VALLEY CA
92708-3847
US

V. Phone/Fax

Practice location:
  • Phone: 909-714-3672
  • Fax:
Mailing address:
  • Phone: 714-793-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KHOI NGO
Title or Position: CEO
Credential:
Phone: 714-793-0550