Provider Demographics
NPI:1104803444
Name:FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Entity type:Organization
Organization Name:FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGARDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-777-7411
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
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-8506
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
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:2005-12-28
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235736Medicaid
CT004235736Medicaid