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Organization
PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC
Active
Organization
PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DOMENIC IACOVONE (PRESIDENT)
(772) 631-1563
Entity
Organization
Contact information
Practice address
4865 SW GOLFSIDE DR, PALM CITY, FL 34990-7917
(772) 631-1563
(772) 463-2344
Mailing address
4865 SW GOLFSIDE DR, PALM CITY, FL 34990-7917
(772) 631-1563
(772) 463-2344
Taxonomy
Speciality
Code
Description
License number
State
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
OS10791
FL
261QM1300X
Multi-Specialty Clinic/Center
Primary
OS10791
FL
Other
Enumeration date
06/06/2017
Last updated
07/21/2022
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