NPIMap

Organization Active NPI

Adventist Health Clearlake Hospital Inc.

Doing business as Adventist Health Clear Lake

  • Critical Access Hospital
  • Clearlake, CA
National Provider Identifier
1124018031
Registry record updated Sep 15, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
110000174 Issued in CA
Legal business name
ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Doing business as
Adventist Health Clear Lake
Practice address
15630 18TH Ave
Clearlake, CA 95422-6710
Phone
(707) 994-6486
Fax
(707) 995-3631
NPI assigned
Oct 24, 2005
Last updated
Sep 15, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 15, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Parker J Pridgen
Title
President
Phone
(707) 467-5200

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X 110000174 CA Primary

Addresses

Primary practice location

15630 18TH Ave
Clearlake, CA 95422-6710

Mailing address

PO Box 888837
Los Angeles, CA 90088-8837

Other identifiers 3

IdentifierTypeStateIssuer
ZZZC1702ZOtherCABLUE SHIELD INPATIENT
ZZR00539GMedicaidCA
HSP40539GMedicaidCA

Other names 1

  • Adventist Health Clear Lake Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.officeally.io:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Bluemark LLC / Office Ally

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20041112000573 CA Part B Supplier - Clinic/Group Practice 3072421197 Receives reassigned benefits from 187 practitioners
1 other NPI on this enrollment
Practice locations: Clearlake, CA
O20071116000572 CA Part A Provider - Critical Access Hospital 3072421197 Receives reassigned benefits from 35 practitioners
Practice locations: Clearlake, CA; Lakeport, CA; Hidden Valley Lake, CA
O20080619000664 CA Part A Provider - Critical Access Hospital 3072421197 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clearlake, CA

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1124018031. Details of each certification follow.

Hospital certification: CCN 051317

Legal name
ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Doing business as
ADVENTIST HEALTH CLEAR LAKE
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Apr 12, 2005
Last certification
Feb 27, 2026
Beds
32
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Aug 14, 1996 in CA
Enrollment address
15630 18TH Ave
Clearlake, CA 95422-9336

Hospital certification: CCN 05Z317

Legal name
ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Doing business as
ADVENTIST HEALTH CLEAR LAKE
Organization structure
CorporationNon-profit
Incorporated
Aug 14, 1996 in CA
Enrollment address
15630 18TH Ave
Clearlake, CA 95422-9336
Hospital Swing-Bed Unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Adventist Health ClearlakeCCN 051317 · All quality measures
Overall star rating
2 of 5
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Locations

15140 Lakeshore Dr
Clearlake, CA 95422
Phone (707) 995-4500

15322 Lakeshore Dr
Ste 202
Clearlake, CA 95422
Phone (707) 994-0303

15322 Lakeshore Dr
Ste 204
Clearlake, CA 95422
Phone (707) 995-5624

15630 18th Ave
#53
Clearlake, CA 95422

4241 Church St
Kelseyville, CA 95451
Phone (707) 279-8813

5290 State St
Kelseyville, CA 95451
Phone (707) 279-8813

5125 Skyway
Paradise, CA 95969
Phone (530) 872-2000

1572 Railroad Ave
Saint Helena, CA 94574

6 Woodland Rd
Ste 205
Saint Helena, CA 94574
Phone (707) 963-6111

821 Saint Helena Hwy S
Saint Helena, CA 94574
Phone (707) 963-5006

Ownership & related parties

All disclosed owners & managing parties 22

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kerry L Heinrich Individual Corporate OfficerChair Jan 1, 2022
Corporate DirectorBoard Member Dec 15, 2014
Velino a Salazar Individual Corporate DirectorBoard Member Sep 15, 2015
Meredith S Jobe Individual Corporate OfficerSecretary Mar 31, 2014
Richard K Reiner Individual Corporate DirectorBoard Member Jan 16, 2017
Joy a. Fehr Individual Corporate DirectorBoard Member Oct 1, 2020
Jonathan J Daggett Individual Corporate DirectorBoard Member Jan 1, 2024
Andrew R Davis Individual Corporate DirectorBoard Member May 5, 2017
Todd N Hofheins Individual Corporate OfficerVice Chair Jan 24, 2022
Ann K Beckett Individual Corporate DirectorBoard Member Jan 1, 2024
Marc K Woodson Individual Corporate DirectorBoard Member Jan 1, 2019
John C Freedman Individual Corporate DirectorBoard Member Sep 26, 2016
Jeffrey R Mock Individual Corporate OfficerTreasurer Sep 18, 2023
Jack W Wagner Individual Corporate DirectorBoard Member Jan 1, 2024
Corporate DirectorBoard Member Dec 1, 2022
Kenneth Jutzy Individual Corporate DirectorBoard Member Jan 1, 2024
Bradford C Newton Individual Corporate DirectorBoard Member Aug 16, 2021
Robert a Cherry Individual Corporate DirectorBoard Member May 5, 2017
Larry L Innocent Individual Corporate DirectorBoard Member Sep 19, 2011
Corporate DirectorBoard Member Jun 1, 2015
Judson Howe Individual Corporate OfficerPresident May 3, 2024
W-2 Managing EmployeePresident May 3, 2024
Adventist Health System/West Organization, Roseville, CA Non-profit Operational/Managerial Control Jul 1, 1997 100%
John H Cress Individual Corporate DirectorBoard Member Oct 1, 2024
Eric a Stevens Individual Corporate OfficerPresident Jul 8, 2024
W-2 Managing Employee Jul 8, 2024
Richard R Riter Individual Corporate OfficerTreasurer Jun 24, 2025

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 105

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 105

Practitioners & affiliated clinicians

Practitioners 242

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 242

Affiliated clinicians 450

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 450

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1130112000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757894400000",
    "number": "1124018031",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 888837",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900888837"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15630 18TH AVE",
            "city": "CLEARLAKE",
            "state": "CA",
            "postal_code": "954226710",
            "telephone_number": "707-994-6486",
            "fax_number": "707-995-3631"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-24",
        "last_updated": "2025-09-15",
        "certification_date": "2025-09-15",
        "status": "A",
        "authorized_official_last_name": "PRIDGEN",
        "authorized_official_first_name": "PARKER",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "707-467-5200"
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "CA",
            "license": "110000174",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD INPATIENT",
            "identifier": "ZZZC1702Z",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZR00539G",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HSP40539G",
            "state": "CA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.officeally.io:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.2019.3",
            "affiliationName": "Bluemark LLC / Office Ally",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "15630 18th Ave",
            "city": "Clearlake",
            "state": "CA",
            "country_code": "US",
            "postal_code": "954226710",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Adventist Health Clear Lake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clearlake, CA

Sources for this page

Verify at the official NPI Registry.