Provider Demographics
NPI:1124204821
Name:ADVENTIST HEALTH CLEARLAKE HOSPITAL, INC-MIDDLETOWN FAMILY HEALTH CENT
Entity Type:Organization
Organization Name:ADVENTIST HEALTH CLEARLAKE HOSPITAL, INC-MIDDLETOWN FAMILY HEALTH CENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-995-5811
Mailing Address - Street 1:PO BOX 6710
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-6710
Mailing Address - Country:US
Mailing Address - Phone:707-994-6486
Mailing Address - Fax:707-995-3631
Practice Address - Street 1:18TH AVE AND HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-6710
Practice Address - Country:US
Practice Address - Phone:707-987-3311
Practice Address - Fax:707-987-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000174261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP08586FMedicaid