Provider Demographics
NPI:1902869829
Name:CLUB HAVEN FAMILY PRACTICE
Entity Type:Organization
Organization Name:CLUB HAVEN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:336-768-9575
Mailing Address - Street 1:2801 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4109
Mailing Address - Country:US
Mailing Address - Phone:336-768-9575
Mailing Address - Fax:336-774-1737
Practice Address - Street 1:2801 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4109
Practice Address - Country:US
Practice Address - Phone:336-768-9575
Practice Address - Fax:336-774-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40378/30659174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01602OtherBCBS OF NC
NC01602OtherBCBS OF NC