Provider Demographics
NPI:1871770768
Name:FAIR HAVEN COMMUNITY HEALTH CLINIC INC.
Entity type:Organization
Organization Name:FAIR HAVEN COMMUNITY HEALTH CLINIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAGARDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-752-5129
Mailing Address - Street 1:374 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-8506
Practice Address - Street 1:339 EASTERN ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-2463
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0722261QD0000X
CT0009261QF0400X
CT0533261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235736Medicaid
CT004235736Medicaid
CTC00591Medicare Oscar/Certification
CT07-1805Medicare PIN