Basic Information
| Provider Information | |||||||||
| NPI: | 1871770768 | ||||||||
| 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: | 339 EASTERN ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065132463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAGARDE | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2037525129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 0722 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QM0801X | 0533 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | 0009 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004235736 | 05 | CT | MEDICAID |