Provider Demographics
NPI:1790870327
Name:LYTLE FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:LYTLE FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDON
Authorized Official - Middle Name:SALDIVAR
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-709-9960
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:VON ORMY
Mailing Address - State:TX
Mailing Address - Zip Code:78073-0324
Mailing Address - Country:US
Mailing Address - Phone:830-709-9960
Mailing Address - Fax:830-709-9962
Practice Address - Street 1:19432 DAVIS ST
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-1601
Practice Address - Country:US
Practice Address - Phone:830-709-9960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0057NCOtherBCBS
TX00206ZMedicare ID - Type Unspecified