Provider Demographics
NPI:1962492876
Name:ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Entity Type:Organization
Organization Name:ADVENTIST HEALTH CLEARLAKE HOSPITAL INC.
Other - Org Name:ADVENTIST HEALTH CLEAR LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSAVAPISITKUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-995-5827
Mailing Address - Street 1:PO BOX 888837
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-8837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5290 STATE ST
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-9450
Practice Address - Country:US
Practice Address - Phone:707-279-8813
Practice Address - Fax:707-279-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2022-12-20
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
CARHM19999GMedicaid
CAZZZ49286ZOtherBLUE SHIELD
CARHM19999GMedicaid