Provider Demographics
NPI:1922625847
Name:GARDNER FAMILY HEALTH NETWORK
Entity Type:Organization
Organization Name:GARDNER FAMILY HEALTH NETWORK
Other - Org Name:SPECIALTY MENTAL HEALTH ALVISO
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 1:160 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:
Mailing Address - Fax:
Practice Address - Street 1:1621 GOLD ST
Practice Address - Street 2:
Practice Address - City:ALVISO
Practice Address - State:CA
Practice Address - Zip Code:95002-3530
Practice Address - Country:US
Practice Address - Phone:408-935-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARDNER FAMILY HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-26
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health