Provider Demographics
NPI:1922680453
Name:GOOD SAM LLC
Entity Type:Organization
Organization Name:GOOD SAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:210-724-8656
Mailing Address - Street 1:8905 EVENING STAR DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-8806
Mailing Address - Country:US
Mailing Address - Phone:702-909-6400
Mailing Address - Fax:
Practice Address - Street 1:3651 LINDELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1254
Practice Address - Country:US
Practice Address - Phone:702-909-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty