Provider Demographics
NPI:1326479759
Name:LORDS OF LOND
Entity Type:Organization
Organization Name:LORDS OF LOND
Other - Org Name:GALAXY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-630-8490
Mailing Address - Street 1:653 N TOWN CENTER DR
Mailing Address - Street 2:114
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0514
Mailing Address - Country:US
Mailing Address - Phone:702-910-6048
Mailing Address - Fax:
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:114
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-910-6048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2019344Medicaid
NV2019344Medicaid
NVC81816Medicare UPIN