Pro Performance Anti Aging and Pharmaceutical Supplementation LLC

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

License

OS10791 Issued in FL

Legal business name

PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC

Practice address

4865 SW Golfside Dr
Palm City, FL 34990-7917

Phone

(772) 631-1563

Fax

(772) 463-2344

NPI assigned

Jun 6, 2017

Last updated

Jul 21, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Domenic Iacovone

Title

President

Phone

(772) 631-1563

Specialties & licenses 2

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1496707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1376072181",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4865 SW GOLFSIDE DR",
            "city": "PALM CITY",
            "state": "FL",
            "postal_code": "349907917",
            "telephone_number": "772-631-1563",
            "fax_number": "772-463-2344"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4865 SW GOLFSIDE DR",
            "city": "PALM CITY",
            "state": "FL",
            "postal_code": "349907917",
            "telephone_number": "772-631-1563",
            "fax_number": "772-463-2344"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO PERFORMANCE ANTI AGING AND PHARMACEUTICAL SUPPLEMENTATION LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-06",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "IACOVONE",
        "authorized_official_first_name": "DOMENIC",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "772-631-1563",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207XX0005X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": "FL",
            "license": "OS10791",
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "FL",
            "license": "OS10791",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP PRACTICE SPECIALITY",
            "identifier": "OS10791",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Multi-Specialty Clinic/Center in Palm City, FL
• Providers in Palm City, FL by specialty
• Multi-Specialty Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.