1164552931 NPI number — GARDNER FAMILY HEALTH NETWORK INC

Table of content: (NPI 1164552931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164552931 NPI number — GARDNER FAMILY HEALTH NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDNER FAMILY HEALTH NETWORK INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164552931
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 GOLD ST.
Provider Second Line Business Mailing Address:
PO BOX 1240
Provider Business Mailing Address City Name:
ALVISO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-935-3933
Provider Business Mailing Address Fax Number:
408-935-3988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1621 GOLD ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALVISO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95002-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-935-3933
Provider Business Practice Location Address Fax Number:
408-935-3988
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORNELL
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR
Authorized Official Telephone Number:
408-579-6178

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: FHC70262F , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HAP11001F . This is a "SOFPALV" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BCP11001F . This is a "BCEDPALV" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EAP11001F . This is a "EAPCALV" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC11001F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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