Basic Information
| Provider Information | |||||||||
| NPI: | 1588263016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIR HAVEN COMMUNITY HEALTH CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037863004 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 SARGENT DR STE 1-300 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065116100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2034971887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2020 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | HERRERA | ||||||||
| AuthorizedOfficialFirstName: | YOLYMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2037777411 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAIR HAVEN COMMUNITY HEALTH CLINIC, INC | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 004235736 | 05 | CT | MEDICAID |