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NPI Code Detail

MEDICARE: FAIR HAVEN COMMUNITY HEALTH CLINIC, INC

MEDICARE: FAIR HAVEN COMMUNITY HEALTH CLINIC, INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QF0400XFederally Qualified Health Center (FQHC)

General Provider Information

NPI Number : 1043679863
Entity Type Code : Organization
Provider Name (Legal Business Name) : FAIR HAVEN COMMUNITY HEALTH CLINIC, INC
Provider Business Mailing Address
First Line : 374 GRAND AVE
Second Line :
City : NEW HAVEN
State : CT
Zip : 06513-3733
Country : US
Telephone Number : 203-777-7411
Fax Number : 203-777-8506
Provider Business Practice Location Address
First Line : 426 EAST ST
Second Line :
City : NEW HAVEN
State : CT
Zip : 06511-5018
Country : US
Telephone Number : 203-777-7411
Fax Number : 203-777-8506
Authorized Official
Title or Position : CEO
Name : SUZANNE P LAGARDE
Credential : MD
Telephone Number : 203-777-7411
Provider Enumeration Date : 02/22/2016
Last Update Date : 02/22/2016

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