Provider Demographics
NPI:1144884826
Name:PROVISIONCARE MEDICAL
Entity type:Organization
Organization Name:PROVISIONCARE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-901-5733
Mailing Address - Street 1:14700 WOODSON PARK DR APT 1512
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77044-4531
Mailing Address - Country:US
Mailing Address - Phone:281-652-5612
Mailing Address - Fax:346-980-4054
Practice Address - Street 1:11501 N SAM HOUSTON PKWY E STE A
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-4635
Practice Address - Country:US
Practice Address - Phone:281-652-5612
Practice Address - Fax:346-980-4054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-28
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty