| Club Haven Family Practice Pa | |
|
2801 Lyndhurst Ave Winston Salem NC 27103-4109 | |
| (336) 768-9575 | |
| (336) 774-1737 |
| Full Name | Club Haven Family Practice Pa |
|---|---|
| Speciality | Family Medicine |
| Location | 2801 Lyndhurst Ave, Winston Salem, North Carolina |
| Authorized Official Name and Position | Mary J Hatley (PRACTICE MANAGER) |
| Authorized Official Contact | 3367689575 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Club Haven Family Practice Pa 2801 Lyndhurst Ave Winston Salem NC 27103-4109 Ph: (336) 768-9575 | Club Haven Family Practice Pa 2801 Lyndhurst Ave Winston Salem NC 27103-4109 Ph: (336) 768-9575 |
| NPI Number | 1922323948 |
|---|---|
| Provider Enumeration Date | 04/01/2010 |
| Last Update Date | 04/30/2015 |
| Medicare PECOS PAC ID | 5092844100 |
|---|---|
| Medicare Enrollment ID | O20100528000295 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922323948 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Thomas Lynn Jolly |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1922069079 PECOS PAC ID: 7012978992 Enrollment ID: I20071205000574 |
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