Provider Demographics
NPI:1558896407
Name:TEAM MAKENA LLC
Entity Type:Organization
Organization Name:TEAM MAKENA LLC
Other - Org Name:RESTORE MOTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-382-3919
Mailing Address - Street 1:27051 TOWNE CENTRE DR STE 180
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6801 PARK TERRACE DRIVE
Practice Address - Street 2:110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1544
Practice Address - Country:US
Practice Address - Phone:949-474-1753
Practice Address - Fax:949-251-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-28
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56330332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier