Organization
CLUB HAVEN FAMILY PRACTICE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THOMAS L. JOLLY MC (OWNER)
(336) 768-9575
Entity
Organization
Contact information
Practice address
2801 LYNDHURST AVE, WINSTON-SALEM, NC 27103-4109
(336) 768-9575
(336) 774-1737
Mailing address
2801 LYNDHURST AVE, WINSTON-SALEM, NC 27103-4109
(336) 768-9575
(336) 774-1737
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
40378/30659
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01602
BCBS OF NC
NC
Enumeration date
04/11/2006
Last updated
08/22/2020
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