MEDICARE: REGENESIS NUTRITION A MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1006X	Metabolic Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1427905058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENESIS NUTRITION A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	4265 MARINA CITY DR UNIT 1011
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-5801
Country	:	US
Telephone Number	:	818-515-6598
Fax Number	:

Provider Business Practice Location Address
First Line	:	4333 ADMIRALTY WAY UNIT 3
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-5469
Country	:	US
Telephone Number	:	818-515-6598
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VICTOR GERMAN TAMASHIRO
Credential	:
Telephone Number	:	818-515-6598

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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