# PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376072181
- **Authorized official:** MR. DOMENIC IACOVONE (PRESIDENT)
- **Authorized official phone:** (772) 631-1563

## Contact information

- **Practice address:** 4865 SW GOLFSIDE DR, PALM CITY, FL 34990-7917
- **Practice address phone:** (772) 631-1563
- **Practice address fax:** (772) 463-2344
- **Mailing address:** 4865 SW GOLFSIDE DR, PALM CITY, FL 34990-7917
- **Mailing address phone:** (772) 631-1563
- **Mailing address fax:** (772) 463-2344

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | OS10791 | FL | — |
| 261QM1300X | Multi-Specialty Clinic/Center | OS10791 | FL | Yes |

## Other

- **Enumeration date:** 06/06/2017
- **Last updated:** 07/21/2022