Provider Demographics
NPI:1063685311
Name:GARDNER FAMILY HEALTH NETWORK
Entity Type:Organization
Organization Name:GARDNER FAMILY HEALTH NETWORK
Other - Org Name:PROYECTO PRIMAVERA
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-938-2113
Mailing Address - Street 1:160 E VIRGINIA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5865
Mailing Address - Country:US
Mailing Address - Phone:408-938-2113
Mailing Address - Fax:408-579-6143
Practice Address - Street 1:160 E VIRGINIA ST STE 264
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5848
Practice Address - Country:US
Practice Address - Phone:408-977-1591
Practice Address - Fax:408-998-1535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARDNER FAMILY HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-08
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29759ZMedicare PIN