Healthcare Provider Details

I. General information

NPI: 1700764545
Provider Name (Legal Business Name): ANTHONY MEDINA REGISTERED DIETITIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16531 REGINA CIR APT 3
HUNTINGTON BEACH CA
92649-3625
US

IV. Provider business mailing address

16531 REGINA CIR APT 3
HUNTINGTON BEACH CA
92649-3625
US

V. Phone/Fax

Practice location:
  • Phone: 562-665-8196
  • Fax:
Mailing address:
  • Phone: 562-665-8196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number86331804
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number86331804
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86331804
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number86331804
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: