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Organization
PROVISIONCARE MEDICAL
Active
Organization
PROVISIONCARE MEDICAL
Active
Other names
MancaveMD
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DERRICK TRAYLOR (CEO)
(503) 901-5733
Entity
Organization
Contact information
Practice address
11501 N SAM HOUSTON PKWY E STE A, HUMBLE, TX 77396-4635
(281) 652-5612
(346) 980-4054
Mailing address
14700 WOODSON PARK DR APT 1512, HOUSTON, TX 77044-4531
(281) 652-5612
(346) 980-4054
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
04/28/2019
Last updated
06/11/2019
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