MEDICARE: REDEFYNE- SKIN & BODY REVIVAL

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1598560575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REDEFYNE- SKIN & BODY REVIVAL

Provider Business Mailing Address
First Line	:	875 E NINE MILE RD STE 6
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32514-1708
Country	:	US
Telephone Number	:	850-542-7413
Fax Number	:

Provider Business Practice Location Address
First Line	:	875 E NINE MILE RD STE 6
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32514-1708
Country	:	US
Telephone Number	:	850-542-7413
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN PHAM
Credential	:	NP
Telephone Number	:	850-207-4063

Provider Enumeration Date	:	02/14/2025
Last Update Date	:	02/14/2025

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Directions to “REDEFYNE- SKIN & BODY REVIVAL ” Practice Location

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