Covered Entity Details

CAH051317-09 Adventist Health Clearlake Hospital, Inc. (Active) - information as of 5/2/2025 10:32:37 PM

Main Details

Name

Adventist Health Clearlake Hospital, Inc.

Subdivision Name

Konocti Wellness Center / Konocti Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051317-09

Medicare Provider Number

051317

Outpatient Facility Provider Number

058681

Additional Details

Current Program Status

Active

Registration Date

10/14/2016

Participating Start Date

1/1/2017

Participating Approval Date

10/28/2016

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Adventist Health North Coast Network
Jeff Mock, Finance Officer, North Coast Network
(916) 406-1417

Primary Contact

St Helena Hospital Clearlake
Jacarre Shelton, Director of Pharmacy
(707) 995-5800

Addresses

Street Address

9430 Lake Street
Building C
Lower Lake, CA 95457

Billing Address

Adventist Health Clear Lake
15630 18th Avenue
Clearlake, CA 95422

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	058681	1124018031,1841626587

Shipping Addresses

Shipping Address 1

Adventist Health Clear Lake
15630 18th Avenue
Clearlake, CA 95422

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH051317-01	Child	CAH	Adventist Health Clearlake Hospital, Inc.	St. Helena Family Health Center	15230 Lakeshore Drive	Clearlake	CA	Active
CAH051317-02	Child	CAH	Adventist Health Clearlake Hospital, Inc.	St. Helena Family Health Center	21337 Bush Street	Middletown	CA	Active
CAH051317-03	Child	CAH	Adventist Health Clearlake Hospital, Inc.	St. Helena Family Health Center	5290 State Street	Kelseyville	CA	Active
CAH051317-06	Child	CAH	Adventist Health Clearlake Hospital, Inc.	Live Well	15230 Lakeshore Drive	Clearlake	CA	Active
CAH051317-08	Child	CAH	Adventist Health Clearlake Hospital, Inc.	St. Helena Medical Specialties Suite 101	15230 Lakeshore Drive	Clearlake	CA	Active
CAH051317-09	Child	CAH	Adventist Health Clearlake Hospital, Inc.	Konocti Wellness Center / Konocti Clinic	9430 Lake Street	Lower Lake	CA	Active
CAH051317-10	Child	CAH	Adventist Health Clearlake Hospital, Inc.	Hidden Valley Multispecialities - Internal Medicine / Primary Care	18990 Coyote Valley Rd	Hidden Valley Lake	CA	Active
CAH051317-11	Child	CAH	Adventist Health Clearlake Hospital, Inc.	Adventist Health Medical Office Lakeport - Primary and Speciality Care	801 11th Street	Lakeport	CA	Active
CAH051317-12	Child	CAH	Adventist Health Clearlake Hospital, Inc.	Hilltop RHC Family Medicine & Specialty - Family Medicine, General Surgery & Cardiology	15322 Lakeshore Dr	Clearlake	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 11:34:40 AM	8/18/2024 7:18:21 PM	8/18/2024 7:18 PM
Contacts	Authorizing Official	Update	Change Request	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	Mock, Jeff Finance Officer, North Coast Network Adventist Health North Coast Network 9164061417	9/27/2023 1:03 PM
Details	Last Recertification Date	Update	Recertification	9/16/2022 6:12:40 PM	9/6/2023 11:34:40 AM	9/6/2023 11:34 AM
Contacts	Authorizing Official	Update	Change Request	JACOBSON, CARLTON Edward CFO St Helena Hospital Clearlake 7079955824	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	5/24/2023 6:26 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 6:23:34 PM	9/16/2022 6:12:40 PM	9/16/2022 6:12 PM
Contacts	Authorizing Official	Update	New Registration	JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	JACOBSON, CARLTON Edward CFO St Helena Hospital Clearlake 7079955824	4/13/2022 8:04 PM
Contacts	Signed By	Update	New Registration	JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	JACOBSON, CARLTON Edward CFO St Helena Hospital Clearlake 7079955824	4/13/2022 8:04 PM
Details	Last Recertification Date	Update	Recertification	9/16/2020 4:47:47 PM	9/9/2021 6:23:34 PM	9/9/2021 6:23 PM
Addresses	Main Address	Update	Change Request	9340 Lake Street Building C Lower Lake, CA 95457	9430 Lake Street Building C Lower Lake, CA 95457	11/16/2020 8:08 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1124018031	11/16/2020 8:08 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	11/16/2020 8:08 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1841626587	11/16/2020 8:08 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	11/16/2020 8:08 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 1:05:34 PM	9/16/2020 4:47:47 PM	9/16/2020 4:47 PM
Details	Entity Name	Update	Change Request	St Helena Hospital Clearlake	Adventist Health Clearlake Hospital, Inc.	7/15/2020 10:10 AM
Addresses	Billing Address	Insert	Recertification		Adventist Health Clear Lake 15630 18th Avenue Clearlake, CA 95422	8/26/2019 1:05 PM
Addresses	Shipping Address	Insert	Recertification		Adventist Health Clear Lake 15630 18th Avenue Clearlake, CA 95422	8/26/2019 1:05 PM
Addresses	Main Address	Update	Recertification	9340 C Lake Street Lower Lake, CA 95457	9340 Lake Street Building C Lower Lake, CA 95457	8/26/2019 1:05 PM
Details	Last Recertification Date	Update	Recertification	9/7/2018 8:35:44 PM	8/26/2019 1:05:34 PM	8/26/2019 1:05 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 12:18:53 PM	9/7/2018 8:35:44 PM	9/7/2018 8:35 PM
Contacts	Primary Contact	Update	Recertification	JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	Shelton, Jacarre Director of Pharmacy St Helena Hospital Clearlake 7079955800	12/4/2017 12:18 PM
Details	Last Recertification Date	Update	Recertification		12/4/2017 12:18:53 PM	12/4/2017 12:18 PM
Contacts	Authorizing Official	Update		JACOBSON, CARLTON CFO 7079955824	JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	12/4/2017 11:57 AM
Contacts	Primary Contact	Update		JACOBSON, CARLTON CFO 7079955824	JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	12/4/2017 11:57 AM
Contacts	Signed By	Update		JACOBSON, CARLTON CFO 7079955824	JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	12/4/2017 11:57 AM
Contacts	Authorizing Official	Insert			JACOBSON, CARLTON CFO 7079955824	4/26/2017 10:05 AM
Contacts	Primary Contact	Insert			JACOBSON, CARLTON CFO 7079955824	4/26/2017 10:05 AM
Contacts	Signed By	Insert			JACOBSON, CARLTON CFO 7079955824	4/26/2017 10:05 AM
Dates	Participating Approval Date	Update			10/28/2016 12:00:00 AM	10/28/2016 4:43 PM
Details	State	Update		Pending	Active	10/28/2016 4:43 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	10/28/2016 4:43 PM
Addresses	Main Address	Insert			9340 C Lake Street Lower Lake, CA 95457	10/28/2016 4:43 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73361	CAH051317-09	10/27/2016 2:46 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73361	10/14/2016 6:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2016 6:13 PM
Medicaid Billing	Medicaid: Number	Insert			058681	10/14/2016 6:13 PM
Medicaid Billing	Medicaid: State	Insert			CA	10/14/2016 6:13 PM
Details	Last Recertification Date	Insert				10/14/2016 6:13 PM
Details	Grant Number	Insert				10/14/2016 6:13 PM
Details	340B ID	Insert				10/14/2016 6:13 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2016 6:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2016 6:13 PM
Details	Medicare Provider Number	Insert			051317	10/14/2016 6:13 PM
Details	Entity Name	Insert			St Helena Hospital Clearlake	10/14/2016 6:13 PM
Details	Program Code	Insert			CAH	10/14/2016 6:13 PM
Details	Entity Subname	Insert			Konocti Wellness Center / Konocti Clinic	10/14/2016 6:13 PM
Dates	Participating Approval Date	Insert				10/14/2016 6:13 PM
Details	State	Insert			Pending	10/14/2016 6:13 PM
Dates	Registration Date	Insert			10/14/2016 12:00:00 AM	10/14/2016 6:13 PM
Dates	Signed By Date	Insert			10/14/2016 12:00:00 AM	10/14/2016 6:13 PM
Dates	Start Date	Insert				10/14/2016 6:13 PM
Terminations	Termination Comments	Insert				10/14/2016 6:13 PM
Terminations	Termination Date	Insert				10/14/2016 6:13 PM
Terminations	Termination Effective Date	Insert				10/14/2016 6:13 PM
Terminations	Termination Reason	Insert				10/14/2016 6:13 PM