Adventist Health Clearlake Hospital Inc.
Organization Active NPI Rural Health Clinic/Center · Kelseyville, CA
NPI 1962492876 · NPPES record last updated Sep 15, 2025
Key facts
- NPI
- 1962492876
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 110000174 (CA)
- Legal business name
- ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
- Practice address
- 5290 State St
Kelseyville, CA 95451-9450 - Phone
- (707) 279-8813
- Fax
- (707) 279-2241
- NPI assigned
- Oct 24, 2005
- Organization subpart
- No
Authorized official
- Name
- Parker J Pridgen
- Title
- President
- Phone
- (707) 467-5200
Owners & managing parties with NPI records 1
-
Kenneth Jutzy, M.D.
Other NPIs with the same Medicare PAC ID 11
Corporate family (same tax ID) 10
Related certifications (CCN) 1
Facilities with the same owner 105
Practitioners 84
-
Pari Azari, M.D.
-
Erin Bennett, MSN, APRN, FNP-BC
-
Ruben R Brechner, M.D.
-
Susan Carreon, M.S.W.
-
Amber Leighan Chatwin, M.D.
-
Jack L Chen, M.D.
-
Andrew K Chinnock, FNP
-
Leonardo C. Clavijo, M.D.
-
William Duge, MD
-
Juan C. Esteva, MD
-
Delmer Fjarli, M.D.
-
William V Glenn, MD
-
Laurie K Halversen, LCSW
-
Curtis Han, DC
-
David Bruce Jackson, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0866946 | Adventist Health Clear Lake Medical Office | Certificate of waiver | Feb 18, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
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
- Corporation · Non-profit
- Incorporated
- Aug 14, 1996 in CA
- Enrollment address
- 5290 State St
Kelseyville, CA 95451-9450 - Related CCNs
- 051317
All disclosed owners & managing parties 18
| Name | Role | Since | Share |
|---|---|---|---|
| Kerry L Heinrich |
Corporate Officer |
Jan 1, 2022 | |
| Corporate Director |
Dec 15, 2014 | ||
| John H Cress |
Corporate Director |
Oct 1, 2024 | |
| Meredith S Jobe |
Corporate Officer |
Mar 31, 2014 | |
| Eric a Stevens |
Corporate Officer |
Jul 8, 2024 | |
| W-2 Managing Employee | Jul 8, 2024 | ||
| Richard K Reiner |
Corporate Director |
Jan 16, 2017 | |
| Joy a. Fehr |
Corporate Director |
Oct 1, 2020 | |
| Jonathan J Daggett |
Corporate Director |
Jan 1, 2024 | |
| Richard R Riter |
Corporate Officer |
Jun 24, 2025 | |
| Andrew R Davis |
Corporate Director |
May 5, 2017 | |
| Ann K Beckett |
Corporate Director |
Jan 1, 2024 | |
| Marc K Woodson |
Corporate Director |
Jan 1, 2019 | |
| John C Freedman |
Corporate Director |
Sep 26, 2016 | |
| Jack W Wagner |
Corporate Director |
Dec 1, 2022 | |
| Kenneth Jutzy |
Corporate Director |
Jan 1, 2024 | |
| Bradford C Newton |
Corporate Director |
Aug 16, 2021 | |
| Robert a Cherry |
Corporate Director |
May 5, 2017 | |
| Larry L Innocent |
Corporate Director |
Sep 19, 2011 | |
| Adventist Health System/West |
Operational/Managerial Control | Jul 1, 1997 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100308000333 | CA | Part a Provider - Rural Health Clinic | 3072421197 | Practice locations: Kelseyville, CA |
National Provider Directory
- Tax ID family
- Rebud Community Hospita
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 110000174 | CA | Yes |
Addresses
Primary practice location
5290 State St
Kelseyville, CA 95451-9450
Mailing address
PO Box 888837
Los Angeles, CA 90088-8837
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ZZZ49286Z | Other | CA | BLUE SHIELD |
| RHM19999G | Medicaid | CA |
Other names
- Adventist Health Clear Lake
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.officeally.io:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service | Other | Bluemark LLC / Office Ally |
Other providers in Kelseyville, CA
- Advocates for Independent Living
- Leila Arlene Alvarez
- Kirk G Andrus
- Blue Chair of California
- Bradley Smith Innovative Physical Therapy
All providers in Kelseyville, CA · Rural Health Clinic/Center in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 15, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.