=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659157642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST COAST DIETITIAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2023
-----------------------------------------------------
Last Update Date | 02/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4132 KATELLA AVE STE 100A
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-276-0126
-----------------------------------------------------
Fax | 855-610-2299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17901 PIONEER BLVD STE L113
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90701-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-276-0126
-----------------------------------------------------
Fax | 855-610-2299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | AUSTIN BOU
-----------------------------------------------------
Credential | RD, CDCES
-----------------------------------------------------
Telephone | 562-276-8057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------