Provider Demographics
NPI:1922424712
Name:DR. SAM, INC.
Entity Type:Organization
Organization Name:DR. SAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ DE VICTORIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:786-299-7548
Mailing Address - Street 1:12651 S. DIXIE HWY
Mailing Address - Street 2:SUITE 327
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5964
Mailing Address - Country:US
Mailing Address - Phone:786-299-7548
Mailing Address - Fax:305-253-3078
Practice Address - Street 1:12651 S DIXIE HWY
Practice Address - Street 2:SUITE 327
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5975
Practice Address - Country:US
Practice Address - Phone:786-299-7548
Practice Address - Fax:305-253-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9101101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty