Provider Demographics
NPI:1255835211
Name:THE REFINERY MEDSPA AND WELLNES, LLC
Entity Type:Organization
Organization Name:THE REFINERY MEDSPA AND WELLNES, LLC
Other - Org Name:PANACEA MEDICAL ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:STOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-917-2217
Mailing Address - Street 1:1115 E RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4630
Mailing Address - Country:US
Mailing Address - Phone:321-917-2217
Mailing Address - Fax:
Practice Address - Street 1:4311 NORFOLK PKWY STE 114
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8617
Practice Address - Country:US
Practice Address - Phone:321-722-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service