GARDNER FAMILY HEALTH NETWORK INC

Provider Demographics

• NPI: 1083654545
• Name: GARDNER FAMILY HEALTH NETWORK INC
• Entity Type: Organization
• Organization Name: GARDNER FAMILY HEALTH NETWORK INC
• Other - Org Name: GARDNER FAMILY HEALTH NETWORK INC
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: DIRECTOR
• Authorized Official - First Name: OFELIA
• Authorized Official - Last Name: RUIZ
• Authorized Official - Phone: 408-935-3971
• Mailing Address - Street 1: PO BOX 1240
• Mailing Address - Street 2: 1621 GOLD STREET
• Mailing Address - City: ALVISO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 95002-1240
• Mailing Address - Country: US
• Mailing Address - Phone: 408-935-3933
• Mailing Address - Fax: 408-935-3988
• Practice Address - Street 1: 1621 GOLD STREET
• Practice Address - City: ALVISO
• Practice Address - State: CA
• Practice Address - Zip Code: 95002-1240
• Practice Address - Country: US
• Practice Address - Phone: 408-935-3933
• Practice Address - Fax: 408-935-3988
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-06
• Last Update Date: 2022-01-13

Provider Licenses

State	License ID	Taxonomies
		171M00000X
CA	070000152	261QC1500X
CA	070000045	261QC1500X
CA	070000179	261QC1500X
CA	070000007	261QC1500X
CA	070000481	261QC1500X
CA	FHC70262F	261QF0400X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	261QF0400X	Ambulatory Health Care Facilities	Clinic/Center	Federally Qualified Health Center (FQHC)	Group - Multi-Specialty
No	171M00000X	Other Service Providers	Case Manager/Care Coordinator		Group - Multi-Specialty
No	261QC1500X	Ambulatory Health Care Facilities	Clinic/Center	Community Health	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	FHC11001F	Medicaid
CA	051150	Medicaid
CA	FHC70262F	Medicaid
CA	FHC11531F	Medicaid
CA	751005	Medicaid
CA	FHC70014F	Medicaid
CA	FHC70872F	Medicaid
CA	FHC70262F	Medicaid
CA	FHC11531F	Medicaid
CA	751005	Medicaid
CA	051150	Medicaid