NPIMap

Organization Active NPI

Club Haven Family Practice PA

  • Family Medicine Physician
  • Winston Salem, NC
National Provider Identifier
1922323948
Registry record updated Apr 30, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CLUB HAVEN FAMILY PRACTICE PA
Practice address
2801 Lyndhurst Ave
Winston Salem, NC 27103-4109
Phone
(336) 768-9575
Fax
(336) 774-1737
NPI assigned
Apr 1, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 30, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Mary J Hatley
Title
Practice Manager
Phone
(336) 768-9575

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

2801 Lyndhurst Ave
Winston Salem, NC 27103-4109

Mailing address

2801 Lyndhurst Ave
Winston Salem, NC 27103-4109
Phone (336) 768-9575

National Provider Directory

National Provider Directory

Locations

2801 Lyndhurst Ave
Winston Salem, NC 27103
Phone (336) 768-9575

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1270080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1430352000000",
    "number": "1922323948",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2801 LYNDHURST AVE",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271034109",
            "telephone_number": "336-768-9575",
            "fax_number": "336-774-1737"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2801 LYNDHURST AVE",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271034109",
            "telephone_number": "336-768-9575",
            "fax_number": "336-774-1737"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLUB HAVEN FAMILY PRACTICE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-04-01",
        "last_updated": "2015-04-30",
        "status": "A",
        "authorized_official_last_name": "HATLEY",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "336-768-9575",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Winston Salem, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.