Basic Information
| Provider Information | |||||||||
| NPI: | 1104803444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIR HAVEN COMMUNITY HEALTH CLINIC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAGARDE | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2037777411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 176B00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004235736 | 05 | CT | MEDICAID |