| Details | State | Update | | Approved | Active | 1/1/2025 12:01 AM |
| Addresses | Main Address | Insert | Reinstatement | |
325 South Willis
Suite 202
Visalia, CA 93291 | 10/17/2024 7:31 AM |
| Addresses | Billing Address | Insert | Reinstatement | | Kaweah Delta Health Care District DBA Kaweah Health
400 West Mineral King Avenue
Visalia, CA 93291 | 10/17/2024 7:31 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Reinstatement | | False | 10/17/2024 7:31 AM |
| Medicaid Billing | Medicaid: Number | Insert | Reinstatement | | 50057 | 10/17/2024 7:31 AM |
| Medicaid Billing | Medicaid: State | Insert | Reinstatement | | CA | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: Number | Delete | Reinstatement | 1578081915 (CA) | | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1538545520 | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | CA | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1588663769 | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | CA | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1659735132 | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | CA | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1376566133 | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | CA | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1588663769 | 10/17/2024 7:31 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | AZ | 10/17/2024 7:31 AM |
| Contacts | Signed By | Update | Reinstatement | HERBST, GARY K.
Chief Executive Officer
Kaweah Delta Health Care District
5596242330 | Herbst, Gary K
Chief Executive Officer
Kaweah Delta Health Care District DBA Kaweah Health
5596242330 | 10/17/2024 7:31 AM |
| Details | Last Recertification Date | Update | Reinstatement | 9/9/2022 6:36:10 PM | | 10/17/2024 7:31 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 9/12/2022 12:00:00 AM | | 10/17/2024 7:31 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 1/24/2019 10:01:35 AM | 10/17/2024 7:31:32 AM | 10/17/2024 7:31 AM |
| Details | State | Update | Reinstatement | Terminated | Approved | 10/17/2024 7:31 AM |
| Dates | Registration Date | Update | Reinstatement | 1/10/2019 12:42:31 PM | 10/11/2024 5:24:40 PM | 10/17/2024 7:31 AM |
| Dates | Signed By Date | Update | Reinstatement | 1/19/2019 8:25:46 PM | 10/14/2024 10:41:26 AM | 10/17/2024 7:31 AM |
| Dates | Start Date | Update | Reinstatement | 4/1/2019 12:00:00 AM | 1/1/2025 12:00:00 AM | 10/17/2024 7:31 AM |
| Terminations | Termination Date | Update | Reinstatement | 7/1/2023 12:00:00 AM | | 10/17/2024 7:31 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 12/24/2022 12:00:00 AM | | 10/17/2024 7:31 AM |
| Terminations | Termination Reason | Update | Reinstatement | Business decision by the Covered Entity | | 10/17/2024 7:31 AM |
| Details | Comments Public | Insert | Reinstatement | | Participating Start Date4/1/2019, Termination 7/1/2023, Reinstatement 1/1/2025 | 10/14/2024 11:21 AM |
| Details | State | Update | | To Be Terminated | Terminated | 7/1/2023 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 9/12/2022 12:00:00 AM | 4/12/2023 12:02 PM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 4/12/2023 12:02 PM |
| Terminations | Termination Date | Update | Termination Request | | 7/1/2023 12:00:00 AM | 4/12/2023 12:02 PM |
| Terminations | Termination Effective Date | Update | Termination Request | | 12/24/2022 12:00:00 AM | 4/12/2023 12:02 PM |
| Terminations | Termination Reason | Update | Termination Request | | Business decision by the Covered Entity | 4/12/2023 12:02 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1588663769 (AZ) | | 9/9/2022 6:36 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1578081915 | 9/9/2022 6:36 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/9/2022 6:36 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1588663769 (CA) | | 9/9/2022 6:36 PM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2021 11:55:56 AM | 9/9/2022 6:36:10 PM | 9/9/2022 6:36 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Noeske, Keri Lynn
CNO Acting CEO
Kaweah Health Medical Center
5596245916 | Herbst, Gary K
Chief Executive Officer
Kaweah Delta Health Care District DBA Kaweah Health
5596242330 | 9/2/2022 6:54 AM |
| Contacts | Primary Contact | Update | Group Change Request | Anderson, Jill C
Pharmacy Business Manager
Kaweah Delta Health Care District DBA Kaweah Health
5596245091 | Gonzalez, Allison E
Pharmacy Business Manager
Kaweah Delta Health Care District DBA Kaweah Health
5596245328 | 7/29/2022 12:44 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Herbst, Gary K
Chief Executive Officer
Kaweah Delta Health Care District DBA Kaweah Health
5596242330 | Noeske, Keri Lynn
CNO Acting CEO
Kaweah Health Medical Center
5596245916 | 7/15/2022 10:01 AM |
| Details | Last Recertification Date | Update | Recertification | 9/14/2020 12:07:35 PM | 8/18/2021 11:55:56 AM | 8/18/2021 11:55 AM |
| Addresses | Shipping Address | Delete | Change Request | Kaweah Delta Health Care District
400 W. Mineral King Ave
Visalia, CA 93291 | | 6/30/2021 6:58 AM |
| Addresses | Main Address | Update | Change Request |
202 W. Willow Ave Suite 202
Visalia, CA 93291 |
202 West Willow Street
Suite 202
Visalia, CA 93291 | 6/30/2021 6:58 AM |
| Addresses | Billing Address | Update | Change Request | Kaweah Delta Health Care District
400 W. Mineral King Ave
Visalia, CA 93291 | Kaweah Delta Health Care District DBA Kaweah Health
400 West Mineral King Avenue
Visalia, CA 93291 | 6/30/2021 6:58 AM |
| Addresses | Shipping Address | Insert | Change Request | | Kaweah Delta Health Care District DBA Kaweah Health
400 West Mineral King Avenue
Visalia, CA 93291 | 6/30/2021 6:58 AM |
| Details | Entity Subname | Update | Change Request | Kaweah Delta Neurosciences Center - Neurology Clinic | Kaweah Health Neurosciences Center | 6/30/2021 6:58 AM |
| Contacts | Primary Contact | Update | Change Request | Abercrombie, Catherine
Pharmacy Business Coordinator
Kaweah Delta Health Care District
5596244529 | Anderson, Jill C
Pharmacy Business Manager
Kaweah Delta Health Care District DBA Kaweah Health
5596245091 | 6/17/2021 4:24 PM |
| Contacts | Authorizing Official | Update | Change Request | HERBST, GARY K.
Chief Executive Officer
Kaweah Delta Health Care District
5596242330 | Herbst, Gary K
Chief Executive Officer
Kaweah Delta Health Care District DBA Kaweah Health
5596242330 | 6/1/2021 3:01 PM |
| Details | Entity Name | Update | Change Request | KAWEAH DELTA HEALTH CARE DISTRICT | Kaweah Delta Health Care District DBA Kaweah Health | 6/1/2021 3:01 PM |
| Addresses | Shipping Address | Delete | Recertification | Kaweah Delta Health Care District
400 W. Mineral King Ave
Visalia, CA 93291 | | 9/14/2020 12:07 PM |
| Addresses | Main Address | Update | Recertification |
202 W. Willow Ave Suite 302
Visalia, CA 93291 |
202 W. Willow Ave Suite 202
Visalia, CA 93291 | 9/14/2020 12:07 PM |
| Addresses | Shipping Address | Insert | Recertification | | Kaweah Delta Health Care District
400 W. Mineral King Ave
Visalia, CA 93291 | 9/14/2020 12:07 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/14/2020 12:07 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | ZZT40057F | 9/14/2020 12:07 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | CA | 9/14/2020 12:07 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/14/2020 12:07 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 024688 | 9/14/2020 12:07 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | AZ | 9/14/2020 12:07 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1588663769 | 9/14/2020 12:07 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | AZ | 9/14/2020 12:07 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 9/14/2020 12:07 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 1:23:06 PM | 9/14/2020 12:07:35 PM | 9/14/2020 12:07 PM |
| Addresses | Shipping Address | Insert | Change Request | | Kaweah Delta Health Care District
400 W. Mineral King Ave
Visalia, CA 93291 | 11/6/2019 7:30 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/26/2019 1:23:06 PM | 8/26/2019 1:23 PM |
| Addresses | Main Address | Update | Change Request |
400 E Mineral King AVe
Visalia, CA 93291 |
202 W. Willow Ave Suite 302
Visalia, CA 93291 | 8/2/2019 9:00 AM |
| Addresses | Billing Address | Update | Change Request | Kaweah Delta Health Care District
400 E Mineral King AVe
400 E Mineral King AVe
Visalia, CA 93291 | Kaweah Delta Health Care District
400 W. Mineral King Ave
Visalia, CA 93291 | 8/2/2019 9:00 AM |
| Details | State | Update | | Approved | Active | 4/1/2019 12:05 AM |
| Contacts | Signed By | Insert | New Registration | | HERBST, GARY K.
Chief Executive Officer
Kaweah Delta Health Care District
5596242330 | 1/24/2019 10:01 AM |
| Details | 340B ID | Update | New Registration | | DSH050057AD | 1/24/2019 10:01 AM |
| Details | Entity Name | Update | New Registration | KAWEAH DELTA MEDICAL CENTER | KAWEAH DELTA HEALTH CARE DISTRICT | 1/24/2019 10:01 AM |
| Details | Entity Subname | Update | New Registration | Kaweah Delta Neurosciences Center | Kaweah Delta Neurosciences Center - Neurology Clinic | 1/24/2019 10:01 AM |
| Dates | Participating Approval Date | Update | New Registration | | 1/24/2019 10:01:35 AM | 1/24/2019 10:01 AM |
| Details | State | Update | New Registration | Pending | Approved | 1/24/2019 10:01 AM |
| Dates | Signed By Date | Update | New Registration | | 1/19/2019 8:25:46 PM | 1/24/2019 10:01 AM |
| Dates | Start Date | Update | New Registration | | 4/1/2019 12:00:00 AM | 1/24/2019 10:01 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | HERBST, GARY K.
SR VP/CFO
Kaweah Delta Health Care District
5596242496 | HERBST, GARY K.
Chief Executive Officer
Kaweah Delta Health Care District
5596242330 | 1/19/2019 8:26 PM |
| Addresses | Main Address | Insert | New Registration | |
400 E Mineral King AVe
Visalia, CA 93291 | 1/10/2019 12:42 PM |
| Addresses | Billing Address | Insert | New Registration | | Kaweah Delta Health Care District
400 E Mineral King AVe
400 E Mineral King AVe
Visalia, CA 93291 | 1/10/2019 12:42 PM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1588663769 | 1/10/2019 12:42 PM |
| Contacts | Authorizing Official | Insert | New Registration | | HERBST, GARY K.
SR VP/CFO
Kaweah Delta Health Care District
5596242496 | 1/10/2019 12:42 PM |
| Contacts | Primary Contact | Insert | New Registration | | Abercrombie, Catherine
Pharmacy Business Coordinator
Kaweah Delta Health Care District
5596244529 | 1/10/2019 12:42 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Details | Grant Number | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Details | 340B ID | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 050057 | 1/10/2019 12:42 PM |
| Details | Entity Name | Insert | New Registration | | KAWEAH DELTA MEDICAL CENTER | 1/10/2019 12:42 PM |
| Details | Program Code | Insert | New Registration | | DSH | 1/10/2019 12:42 PM |
| Details | Entity Subname | Insert | New Registration | | Kaweah Delta Neurosciences Center | 1/10/2019 12:42 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Details | State | Insert | New Registration | | Pending | 1/10/2019 12:42 PM |
| Dates | Registration Date | Insert | New Registration | | 1/10/2019 12:42:31 PM | 1/10/2019 12:42 PM |
| Dates | Signed By Date | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Dates | Start Date | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Terminations | Termination Date | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 1/10/2019 12:42 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 1/10/2019 12:42 PM |