MEDICARE: RESTORE LIFE SERVICES, 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	251B00000X	Case Management Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447802558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE LIFE SERVICES, LLC

Provider Business Mailing Address
First Line	:	4340 N HIAWASSEE RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-1702
Country	:	US
Telephone Number	:	407-284-3128
Fax Number	:	407-297-7887

Provider Business Practice Location Address
First Line	:	4340 N HIAWASSEE RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-1702
Country	:	US
Telephone Number	:	407-284-3128
Fax Number	:	407-297-7887

Authorized Official
Title or Position	:	EXECUTIVE ADMINISTRATOR
Name	:	KATHY LYNN JONES
Credential	:
Telephone Number	:	407-234-5536

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	07/23/2020

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Directions to “RESTORE LIFE SERVICES, LLC ” Practice Location

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