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
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OS10791
GROUP PRACTICE SPECIALITY
FL
Enumeration date
06/06/2017
Last updated
07/21/2022
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