Provider Demographics
NPI:1316064900
Name:HODGE, LYLE MARTIN (DC)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:MARTIN
Last Name:HODGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W WINTERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4423
Mailing Address - Country:US
Mailing Address - Phone:469-323-7322
Mailing Address - Fax:
Practice Address - Street 1:223 W WINTERGREEN RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4423
Practice Address - Country:US
Practice Address - Phone:469-323-7322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3029111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0012650-01Medicaid
TX601523Medicare PIN
TX0012650-01Medicaid