Provider Demographics
NPI:1588263016
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:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YOLYMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
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:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-786-3004
Practice Address - Street 1:150 SARGENT DR STE 1-300
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6100
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-497-1887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIR HAVEN COMMUNITY HEALTH CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235736Medicaid