Provider Demographics
NPI:1841736501
Name:REFINE THE BODY INC
Entity type:Organization
Organization Name:REFINE THE BODY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-753-3400
Mailing Address - Street 1:1300 N 500 E STE 260
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2417
Mailing Address - Country:US
Mailing Address - Phone:435-753-3400
Mailing Address - Fax:
Practice Address - Street 1:1300 N 500 E STE 260
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2417
Practice Address - Country:US
Practice Address - Phone:435-753-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1788161205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528645618002Medicaid
UT528645618002Medicaid