=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326479759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LORDS OF LOND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2013
-----------------------------------------------------
Last Update Date | 12/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 653 N TOWN CENTER DR 114
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144-0514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-910-6048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 653 N TOWN CENTER DR 114
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144-0514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-910-6048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | WENDELL D BUTLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-630-8490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5642
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------