Healthcare Provider Details

I. General information

NPI: 1790870327
Provider Name (Legal Business Name): LYTLE FAMILY PRACTICE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19432 DAVIS ST
LYTLE TX
78052-1601
US

IV. Provider business mailing address

PO BOX 324
VON ORMY TX
78073-0324
US

V. Phone/Fax

Practice location:
  • Phone: 830-709-9960
  • Fax:
Mailing address:
  • Phone: 830-709-9960
  • Fax: 830-709-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK7753
License Number StateTX

VIII. Authorized Official

Name: DR. GLENDON SALDIVAR HACK
Title or Position: PRESIDENT
Credential: MD
Phone: 830-709-9960