Provider Demographics
NPI:1376072181
Name:PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC
Entity Type:Organization
Organization Name:PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:
Authorized Official - Last Name:IACOVONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-631-1563
Mailing Address - Street 1:4865 SW GOLFSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-7917
Mailing Address - Country:US
Mailing Address - Phone:772-631-1563
Mailing Address - Fax:772-463-2344
Practice Address - Street 1:4865 SW GOLFSIDE DR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-7917
Practice Address - Country:US
Practice Address - Phone:772-631-1563
Practice Address - Fax:772-463-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10791207XX0005X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS10791OtherGROUP PRACTICE SPECIALITY