1144884826 NPI number — PROVISIONCARE MEDICAL

Table of content: (NPI 1144884826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144884826 NPI number — PROVISIONCARE MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVISIONCARE MEDICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144884826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14700 WOODSON PARK DR APT 1512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77044-4531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-652-5612
Provider Business Mailing Address Fax Number:
346-980-4054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11501 N SAM HOUSTON PKWY E STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77396-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-652-5612
Provider Business Practice Location Address Fax Number:
346-980-4054
Provider Enumeration Date:
04/28/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TRAYLOR
Authorized Official First Name:
DERRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
503-901-5733

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)