Basic Information
| Provider Information | |||||||||
| NPI: | 1740445477 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GARDNER FAMILY CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E VIRGINIA ST | ||||||||
| Address2: | #280 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951125857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082876200 | ||||||||
| FaxNumber: | 4089981535 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E VIRGINIA ST | ||||||||
| Address2: | #280 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951125857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082876200 | ||||||||
| FaxNumber: | 4089981535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | ZAZUETA | ||||||||
| AuthorizedOfficialFirstName: | CECILY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | QI COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4082876200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 52986 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.