Provider Demographics
NPI:1376109629
Name:GARDNER FAMILY HEALTH NETWORK INC
Entity Type:Organization
Organization Name:GARDNER FAMILY HEALTH NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-579-6178
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:408-579-6178
Mailing Address - Fax:408-579-6143
Practice Address - Street 1:614 TULLY RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1048
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 INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health