Healthcare Provider Details

I. General information

NPI: 1558491043
Provider Name (Legal Business Name): GARDNER FAMILY HEALTH NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 ALUM ROCK AVE
SAN JOSE CA
95127-2807
US

IV. Provider business mailing address

1621 GOLD ST. PO BOX 1240
ALVISO CA
92002-1240
US

V. Phone/Fax

Practice location:
  • Phone: 408-935-3933
  • Fax: 408-935-3988
Mailing address:
  • Phone: 408-935-3933
  • Fax: 408-935-3988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberFHC70262F
License Number StateCA

VIII. Authorized Official

Name: CHRISTINA CORNELL
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 408-579-6178