Basic Information
| Provider Information | |||||||||
| NPI: | 1043679863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIR HAVEN COMMUNITY HEALTH CLINIC, INC | ||||||||
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| OtherOrganizationName: | FAIR HAVEN COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 EAST ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAGARDE | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2037777411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.