Provider Demographics
NPI:1639718182
Name:PROSOURCEPT LLC
Entity Type:Organization
Organization Name:PROSOURCEPT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:215-479-0119
Mailing Address - Street 1:421 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-1671
Mailing Address - Country:US
Mailing Address - Phone:215-479-0119
Mailing Address - Fax:
Practice Address - Street 1:421 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-1671
Practice Address - Country:US
Practice Address - Phone:215-479-0119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy