NPIMap

Organization Active NPI

Adventist Health Clearlake Hospital Inc.

Doing business as Adventist Health Clear Lake

  • Rural Health Clinic/Center
  • Kelseyville, CA
National Provider Identifier
1962492876
Registry record updated Sep 15, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
110000174 Issued in CA
Legal business name
ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Doing business as
Adventist Health Clear Lake
Practice address
5290 State St
Kelseyville, CA 95451-9450
Phone
(707) 279-8813
Fax
(707) 279-2241
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
Rural Health Clinic/Center 261QR1300X 110000174 CA Primary

Addresses

Primary practice location

5290 State St
Kelseyville, CA 95451-9450

Mailing address

PO Box 888837
Los Angeles, CA 90088-8837

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 CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100308000333 CA Part A Provider - Rural Health Clinic 3072421197 Practice locations: Kelseyville, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962492876. Details of each certification follow.

Rural health clinic certification: CCN 553995

Legal name
ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Doing business as
ADVENTIST HEALTH CLEAR LAKE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 13, 1994
Last certification
Jun 16, 2014
Ownership / control type
2B
Most recent change of ownership
Mar 1, 1998 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Aug 14, 1996 in CA
Enrollment address
5290 State St
Kelseyville, CA 95451-9450
Related CCNs
051317

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).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0866946Adventist Health Clear Lake Medical Office5290 State St, Kelseyville, CA 95451Certificate of waiverFeb 18, 2028

National Provider Directory

National Provider Directory
Tax ID family
Rebud Community Hospita11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Locations

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

Ownership & related parties

All disclosed owners & managing parties 18

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
John H Cress Individual Corporate DirectorBoard Member Oct 1, 2024
Meredith S Jobe Individual Corporate OfficerSecretary Mar 31, 2014
Eric a Stevens Individual Corporate OfficerPresident Jul 8, 2024
W-2 Managing Employee Jul 8, 2024
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
Richard R Riter Individual Corporate OfficerTreasurer Jun 24, 2025
Andrew R Davis Individual Corporate DirectorBoard Member May 5, 2017
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
Jack W Wagner Individual 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
Adventist Health System/West Organization, Roseville, CA Corporation, Non-profit, Chain home office Operational/Managerial Control Jul 1, 1997 100%

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

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": "1962492876",
    "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": "5290 STATE ST",
            "city": "KELSEYVILLE",
            "state": "CA",
            "postal_code": "954519450",
            "telephone_number": "707-279-8813",
            "fax_number": "707-279-2241"
        }
    ],
    "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": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "CA",
            "license": "110000174",
            "primary": true
        }
    ],
    "identifiers": [],
    "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": "5290 State St",
            "city": "Kelseyville",
            "state": "CA",
            "country_code": "US",
            "postal_code": "954519450",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Adventist Health Clear Lake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kelseyville, CA

Sources for this page

Verify at the official NPI Registry.