=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891678546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIR HAVEN COMMUNITY HEALTH CLINIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2025
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 W MAIN ST
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-4088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-777-7411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 W MAIN ST
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-4088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-777-7411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | BAIN PATRIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-777-7411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------