{
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"OrgName": "CLUB HAVEN FAMILY PRACTICE",
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"FirstLineMailingAddress": "2801 LYNDHURST AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WINSTON-SALEM",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "27103-4109",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "336-768-9575",
"MailingAddressFaxNumber": "336-774-1737",
"FirstLinePracticeLocationAddress": "2801 LYNDHURST AVE",
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"PracticeLocationAddressCityName": "WINSTON-SALEM",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "336-768-9575",
"PracticeLocationAddressFaxNumber": "336-774-1737",
"EnumerationDate": "04/11/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "JOLLY",
"AuthorizedOfficialFirstName": "THOMAS",
"AuthorizedOfficialMiddleName": "L.",
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MC",
"AuthorizedOfficialTelephoneNumber": "336-768-9575",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Specialist",
"LicenseNumber": "40378/30659",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
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"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}