Provider Demographics
NPI:1598560575
Name:REDEFYNE- SKIN & BODY REVIVAL
Entity type:Organization
Organization Name:REDEFYNE- SKIN & BODY REVIVAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:850-207-4063
Mailing Address - Street 1:875 E NINE MILE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-1708
Mailing Address - Country:US
Mailing Address - Phone:850-542-7413
Mailing Address - Fax:
Practice Address - Street 1:875 E NINE MILE RD STE 6
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-1708
Practice Address - Country:US
Practice Address - Phone:850-542-7413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center