Healthcare Provider Details

I. General information

NPI: 1689239014
Provider Name (Legal Business Name): GARDNER FAMILY HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E VIRGINIA ST STE 100
SAN JOSE CA
95112-5865
US

IV. Provider business mailing address

160 E VIRGINIA ST STE 100
SAN JOSE CA
95112-5865
US

V. Phone/Fax

Practice location:
  • Phone: 408-579-6178
  • Fax: 408-579-6143
Mailing address:
  • Phone: 408-579-6178
  • Fax: 408-579-6143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

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