Provider Demographics
NPI:1922323948
Name:CLUB HAVEN FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:CLUB HAVEN FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
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:2010-04-01
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty