MEDICARE: GARDNER FAMILY HEALTH NETWORK INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1104657501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARDNER FAMILY HEALTH NETWORK INC

Provider Business Mailing Address
First Line	:	2001 COTTLE AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 COTTLE AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3502
Country	:	US
Telephone Number	:	408-287-6200
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	LAURA PEREZ
Credential	:
Telephone Number	:	408-938-2113

Provider Enumeration Date	:	08/08/2024
Last Update Date	:	08/08/2024

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