Healthcare Provider Details

I. General information

NPI: 1447767934
Provider Name (Legal Business Name): FAIR HAVEN COMMUNITY HEALTH CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 SYCAMORE WAY
BRANFORD CT
06405-6551
US

IV. Provider business mailing address

374 GRAND AVE
NEW HAVEN CT
06513-3733
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax: 203-777-8506
Mailing address:
  • Phone: 203-752-5248
  • Fax: 203-786-3004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number0901
License Number StateCT

VIII. Authorized Official

Name: YOLYMAR HERRERA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 203-777-7411