Provider Demographics
NPI:1598740185
Name:VILLAGE OF FAIR HAVEN
Entity Type:Organization
Organization Name:VILLAGE OF FAIR HAVEN
Other - Org Name:FAIR HAVEN AMBULANCE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VILLAGE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:DIGREGORIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-947-5112
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-0535
Mailing Address - Country:US
Mailing Address - Phone:315-635-1789
Mailing Address - Fax:315-635-3289
Practice Address - Street 1:14447 FAIR HAVEN RD
Practice Address - Street 2:
Practice Address - City:FAIR HAVEN
Practice Address - State:NY
Practice Address - Zip Code:13064
Practice Address - Country:US
Practice Address - Phone:315-947-5145
Practice Address - Fax:315-947-5728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10340341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
353927OtherMVP
NY02145077Medicaid
590014704OtherPALMETTO GBA RAILROAD
NY02145077Medicaid