Healthcare Provider Details

I. General information

NPI: 1104803444
Provider Name (Legal Business Name): FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE
NEW HAVEN CT
06513
US

IV. Provider business mailing address

374 GRAND AVE
NEW HAVEN CT
06513
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax: 203-777-8506
Mailing address:
  • Phone: 203-777-7411
  • Fax: 203-777-8506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE LAGARDE
Title or Position: CEO
Credential: MD
Phone: 203-777-7411