Healthcare Provider Details

I. General information

NPI: 1164253563
Provider Name (Legal Business Name): GARDNER FAMILY HEALTH NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 COTTLE AVE
SAN JOSE CA
95125-3504
US

IV. Provider business mailing address

2105 COTTLE AVE
SAN JOSE CA
95125-3504
US

V. Phone/Fax

Practice location:
  • Phone: 408-287-6200
  • Fax:
Mailing address:
  • Phone: 408-287-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

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