Provider Demographics
NPI:1558491043
Name:GARDNER FAMILY HEALTH NETWORK INC
Entity Type:Organization
Organization Name:GARDNER FAMILY HEALTH NETWORK INC
Other - Org Name:COMPRECARE HEALTH CENTER
Other - Org Type:Doing Business As
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 1:1621 GOLD ST.
Mailing Address - Street 2:PO BOX 1240
Mailing Address - City:ALVISO
Mailing Address - State:CA
Mailing Address - Zip Code:92002-1240
Mailing Address - Country:US
Mailing Address - Phone:408-935-3933
Mailing Address - Fax:408-935-3988
Practice Address - Street 1:3030 ALUM ROCK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-2807
Practice Address - Country:US
Practice Address - Phone:408-935-3933
Practice Address - Fax:408-935-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251X00000X
CAFHC70262F261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP70262FOtherBCEDPCCARE
CAFHC70262FMedicaid
CAEAP70262FOtherEAPCCCARE
CAHAP70262FOtherSOFPCCARE
CA051813Medicare ID - Type UnspecifiedUGSCCARE