MEDICARE: PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	OS10791	FL
2	261QM1300X	Multi-Specialty Clinic/Center	OS10791	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OS10791	OTHER	FL	GROUP PRACTICE SPECIALITY

General Provider Information

NPI Number	:	1376072181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC

Provider Business Mailing Address
First Line	:	4865 SW GOLFSIDE DR
Second Line	:
City	:	PALM CITY
State	:	FL
Zip	:	34990-7917
Country	:	US
Telephone Number	:	772-631-1563
Fax Number	:	772-463-2344

Provider Business Practice Location Address
First Line	:	4865 SW GOLFSIDE DR
Second Line	:
City	:	PALM CITY
State	:	FL
Zip	:	34990-7917
Country	:	US
Telephone Number	:	772-631-1563
Fax Number	:	772-463-2344

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DOMENIC IACOVONE
Credential	:
Telephone Number	:	772-631-1563

Provider Enumeration Date	:	06/06/2017
Last Update Date	:	07/21/2022

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