Provider Demographics
NPI:1144358748
Name:GARDNER FAMILY HEALTH NETWORK INC
Entity type:Organization
Organization Name:GARDNER FAMILY HEALTH NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OFELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-935-3971
Mailing Address - Street 1:PO BOX 1240
Mailing Address - Street 2:
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:408-935-3982
Practice Address - Street 1:7526 MONTEREY ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5826
Practice Address - Country:US
Practice Address - Phone:408-935-3933
Practice Address - Fax:408-935-3988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARDNER FAMILY HEALTH NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-02
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251X00000X
CAFHC707872F261QF0400X
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
CAFHC70872FMedicaid
CABCP707872FOtherBCEDPGIL
CAEAP707872FOtherEAPCGIL
CAHAP70872FOtherSOFPGIL
CAFHC70872FMedicaid