Provider Demographics
NPI:1760666291
Name:JOLLY, BOBBY LYNN (ADMINISTRATOR)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:LYNN
Last Name:JOLLY
Suffix:
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 HOLLAND STREET
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-7931
Mailing Address - Country:US
Mailing Address - Phone:828-584-8159
Mailing Address - Fax:828-391-1337
Practice Address - Street 1:5820 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-7931
Practice Address - Country:US
Practice Address - Phone:828-584-8159
Practice Address - Fax:828-391-1337
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker