Provider Demographics
NPI:1447767934
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 COORDINATOR
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:203-752-5248
Mailing Address - Fax:203-786-3004
Practice Address - Street 1:14 SYCAMORE WAY
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-6551
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIR HAVEN COMMUNITY HEALTH CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0901261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)