MEDICARE: ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center	110000174	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ49286Z	OTHER	CA	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962492876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.

Provider Business Mailing Address
First Line	:	PO BOX 888837
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90088-8837
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5290 STATE ST
Second Line	:
City	:	KELSEYVILLE
State	:	CA
Zip	:	95451-9450
Country	:	US
Telephone Number	:	707-279-8813
Fax Number	:	707-279-2241

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PARKER J PRIDGEN
Credential	:
Telephone Number	:	707-467-5200

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	09/15/2025

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