Provider Demographics
NPI:1851599690
Name:LECROY FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:LECROY FAMILY MEDICINE PA
Other - Org Name:LIGHTHOUSE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:LECROY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-424-3774
Mailing Address - Street 1:6515 COLLEYVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6231
Mailing Address - Country:US
Mailing Address - Phone:817-424-3774
Mailing Address - Fax:817-424-3398
Practice Address - Street 1:6515 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6231
Practice Address - Country:US
Practice Address - Phone:817-424-3774
Practice Address - Fax:817-424-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
TXK2736261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty