NPIMap

Organization Active NPI

Fair Haven Community Health Clinic Inc

  • Federally Qualified Health Center (FQHC)
  • New Haven, CT
National Provider Identifier
1104803444
Registry record updated Oct 30, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Practice address
374 Grand Ave
New Haven, CT 06513
Phone
(203) 777-7411
Fax
(203) 777-8506
NPI assigned
Dec 28, 2005
Last updated
Oct 30, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Suzanne Lagarde, MDNPI 1114068848
Title
Ceo
Phone
(203) 777-7411

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X NU
Dental Hygienist 124Q00000X NU
Midwife 176B00000X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

374 Grand Ave
New Haven, CT 06513

Mailing address

374 Grand Ave
New Haven, CT 06513
Phone (203) 777-7411

Other identifiers 1

IdentifierTypeStateIssuer
004235736MedicaidCT

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT17 enrollments

Enrollment records 17

Enrollment IDStateProvider typePAC IDDetails
O20040302000135 CT Part B Supplier - Clinic/Group Practice 4183511538 Receives reassigned benefits from 72 practitioners
5 other NPIs on this enrollment
Practice locations: North Branford, CT; East Haven, CT; New Haven, CT; Branford, CT
O20081121000689 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20090122000080 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20090122000167 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20130716000882 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20130719000549 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20130724000073 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20150105001271 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20180212000572 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: Branford, CT
O20180212000696 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: East Haven, CT
O20180212001946 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: East Haven, CT
O20200422001095 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20230215003023 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: Branford, CT
O20230217002650 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: Branford, CT
O20230705002609 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20231221001330 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT
O20240209001442 CT Part A Provider - Federally Qualified Health Center (FQHC) 4183511538 Practice locations: New Haven, CT

NPI to CCN mapping 16

The Medicare certification numbers (CCNs) connected to NPI 1104803444. Details of each certification follow.

Federally qualified health center certification: CCN 071817

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
FAIR HAVEN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
374 Grand Ave
New Haven, CT 65133733

Federally qualified health center certification: CCN 071805

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
FAIR HAVEN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
339 Eastern St
New Haven, CT 65132463

Federally qualified health center certification: CCN 071807

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
FAIR HAVEN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
164 Grand Ave
New Haven, CT 65133938

Federally qualified health center certification: CCN 071899

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 12, 2013
Last certification
Aug 12, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
100 James St
New Haven, CT 65134222

Federally qualified health center certification: CCN 071806

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
FAIR HAVEN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
181 Mitchell Dr
New Haven, CT 65112515

Federally qualified health center certification: CCN 071900

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
FAIR HAVEN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 26, 2013
Last certification
Aug 26, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972
Enrollment address
293 Clinton Ave
New Haven, CT 65132814

Federally qualified health center certification: CCN 071909

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 11, 2015
Last certification
Feb 11, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 2, 1972 in CT
Enrollment address
50 Grand Ave
New Haven, CT 65133949

Federally qualified health center certification: CCN 071935

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 12, 2018
Last certification
Feb 12, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1971 in CT
Enrollment address
14 Sycamore Way
Branford, CT 64056551

Federally qualified health center certification: CCN 071936

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 12, 2018
Last certification
Feb 12, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
35 Wheelbarrow LN
East Haven, CT 65132003

Federally qualified health center certification: CCN 071934

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 13, 2018
Last certification
Feb 13, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
67 Hudson St
East Haven, CT 65121524

Federally qualified health center certification: CCN 071945

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 22, 2020
Last certification
Apr 22, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 19, 2019 in CT
Enrollment address
374 Grand Ave
New Haven, CT 65133733

Federally qualified health center certification: CCN 071002

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 12, 2023
Last certification
Jan 12, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 1, 1972 in CT
Enrollment address
118 Damascus Rd
Branford, CT 64053979

Federally qualified health center certification: CCN 071007

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
JOHN B SLINEY ELEMENTARY SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 5, 2023
Last certification
Jul 5, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 1, 1972 in CT
Enrollment address
23 Eades St
Branford, CT 64053628

Federally qualified health center certification: CCN 071006

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
FAIR HAVEN COMMUNITY HEALTH CARE AT BISHOP WOODS SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 30, 2023
Last certification
Jun 30, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 1, 1972 in CT
Enrollment address
1481 Quinnipiac Ave
New Haven, CT 65131520

Federally qualified health center certification: CCN 071021

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
LEEWAY HOUSE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 20, 2023
Last certification
Dec 20, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1972 in CT
Enrollment address
40 Albert St
RM MC1
New Haven, CT 65111542

Federally qualified health center certification: CCN 071024

Legal name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Doing business as
ROSS WOODWARD SCHOOL BASED HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 7, 2024
Last certification
Feb 7, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
185 Barnes Ave
New Haven, CT 65131707

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

67 Hudson St
East Haven, CT 06512

Ownership & related parties

All disclosed owners & managing parties 19

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Suzanne P Lagarde Individual Corporate DirectorCeo Jun 24, 2013
Corporate OfficerCeo Jun 24, 2013
W-2 Managing EmployeeCeo Jun 24, 2013
Corporate DirectorCeo Jun 20, 2013 100%
Operational/Managerial ControlCeo Jun 20, 2013 100%
W-2 Managing Employee Jun 24, 2013 100%
Operational/Managerial ControlPresident/Ceo Jun 24, 2013 100%
Corporate OfficerCeo Jun 24, 2013 100%
W-2 Managing EmployeeCeo Jun 24, 2013 100%
Operational/Managerial ControlCeo Jun 24, 2013 100%
Corporate Officer Jun 24, 2013
Operational/Managerial ControlCeo Jun 24, 2013
Francisca Tibo Individual Corporate OfficerBoard Member Jun 19, 2014
Corporate DirectorBoard Member Jun 19, 2014
Corporate OfficerBoard Secretary Jun 19, 2014
William Morico Individual Corporate OfficerBoard Member Oct 1, 1994
Corporate OfficerBoard Member Mar 28, 2018
Corporate DirectorBoard Member Mar 28, 2018
Corporate OfficerBoard Member Apr 1, 1995
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Jose Crespo Individual Corporate OfficerBoard Member Jun 16, 2016
Corporate DirectorBoard Member Jun 16, 2016
Nitza M Diaz Individual Corporate OfficerBoard Member Nov 1, 2005
Corporate OfficerBoard Member Nov 17, 2005
Corporate DirectorBoard Member Nov 1, 2005
Corporate DirectorBoard President Nov 17, 2005
Corporate OfficerBoard President Nov 17, 2005
Corporate DirectorBoard President Nov 1, 2005
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Corporate Director Nov 5, 2005
Enrique Juncadella Individual Corporate OfficerBoard Member Apr 29, 2012
Corporate DirectorBoard Member Apr 29, 2012
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Carla Weil Individual Corporate OfficerBoard Member Jun 16, 2016
Corporate DirectorBoard Member Jun 16, 2016
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Linet a Obura Individual Corporate OfficerBoard Member May 21, 2015
Corporate DirectorBoard Member May 21, 2015
Thomas Candrick Individual Corporate OfficerBoard Member Mar 22, 2012
Corporate DirectorBoard Member Mar 22, 2012
Corporate OfficerBoard Treasurer Mar 22, 2012
Corporate DirectorBoard Treasurer Mar 22, 2012
Corporate DirectorBoard Member Jan 1, 2020
Richard S Stahl Individual Corporate OfficerBoard Member Feb 18, 2015
Corporate DirectorBoard Member Feb 18, 2015
Magda Natal Individual Corporate OfficerBoard Member Jun 17, 2010
Corporate DirectorBoard Member Jun 17, 2010
Corporate OfficerBoard Secretary Jun 17, 2010
Corporate DirectorBoard Secretary Jun 17, 2010
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Tracey I Williams Individual W-2 Managing EmployeeCredentialing/Enrollment Manager Aug 4, 2023
Maria Falconer Individual Corporate OfficerBoard Member Jun 16, 2016
Maribel Martinez Individual Corporate OfficerBoard Member Nov 15, 2017
Corporate DirectorBoard Member Nov 15, 2017
Corporate OfficerBoard President Nov 15, 2017
Corporate DirectorBoard Vice President Nov 15, 2017
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Corporate Officer Nov 15, 2017
Yolymar Santos Melendez Individual W-2 Managing Employee Jun 24, 2017
Operational/Managerial Control Jun 24, 2017
Operational/Managerial ControlCredentialing Manager Jun 24, 2017
Operational/Managerial ControlCredentialing Coordinator Jun 1, 2018
Operational/Managerial ControlCredentialing Coordinator Jun 24, 2017
Operational/Managerial ControlCredentialing Manager Jun 20, 2011
Operational/Managerial ControlCredentailing Coordinator Jul 1, 2017
Evelyn Barnum Individual Corporate OfficerBoard Member Jan 18, 2018
Corporate DirectorBoard Member Jan 18, 2018
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Andrea Simmons Individual Corporate OfficerBoard Vice President Jun 19, 2019
Corporate DirectorBoard Member Jun 19, 2019
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Richard D'Aquila Individual Corporate OfficerBoard Member Nov 19, 2021
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Corporate DirectorBoard Member Nov 29, 2021
John Destefano Individual Corporate OfficerBoard Member Jul 17, 2019
Corporate DirectorBoard Member Jul 17, 2019
OtherBoard Member Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 91

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 91

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1135728000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1414627200000",
    "number": "1104803444",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "374 GRAND AVE",
            "city": "NEW HAVEN",
            "state": "CT",
            "postal_code": "06513",
            "telephone_number": "203-777-7411",
            "fax_number": "203-777-8506"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "374 GRAND AVE",
            "city": "NEW HAVEN",
            "state": "CT",
            "postal_code": "06513",
            "telephone_number": "203-777-7411",
            "fax_number": "203-777-8506"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIR HAVEN COMMUNITY HEALTH CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-28",
        "last_updated": "2014-10-30",
        "status": "A",
        "authorized_official_last_name": "LAGARDE",
        "authorized_official_first_name": "SUZANNE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "203-777-7411",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "176B00000X",
            "taxonomy_group": "",
            "desc": "Midwife",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004235736",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in New Haven, CT

Sources for this page

Verify at the official NPI Registry.