MEDICARE: RESTORATION MEDICINE LLC

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	207VG0400X	Gynecology Physician	ME92412	FL

General Provider Information

NPI Number	:	1386975415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORATION MEDICINE LLC

Provider Business Mailing Address
First Line	:	190 S SYKES CREEK PKWY
Second Line	:	SUITE #3
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3572
Country	:	US
Telephone Number	:	321-305-6254
Fax Number	:	321-305-5972

Provider Business Practice Location Address
First Line	:	190 S SYKES CREEK PKWY
Second Line	:	SUITE #3
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3572
Country	:	US
Telephone Number	:	321-305-6254
Fax Number	:	321-305-5972

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LANCE ANDRE MAKI
Credential	:	M.D.
Telephone Number	:	321-305-6254

Provider Enumeration Date	:	01/29/2010
Last Update Date	:	04/11/2011

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