Provider Demographics
NPI:1790830255
Name:PROSPECT INC.
Entity Type:Organization
Organization Name:PROSPECT INC.
Other - Org Name:PROSPECT SPORTS MEDICINE & REHABILITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:207-626-3333
Mailing Address - Street 1:6 ROCKWOOD DRIVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351-0552
Mailing Address - Country:US
Mailing Address - Phone:207-626-3333
Mailing Address - Fax:207-626-3334
Practice Address - Street 1:6 ROCKWOOD DR.
Practice Address - Street 2:SUITE #2
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-0552
Practice Address - Country:US
Practice Address - Phone:207-626-3333
Practice Address - Fax:207-626-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME060722OtherBLUE CROSS, BLUE SHIELD
MEME0143Medicare ID - Type Unspecified