Covered Entity Details

CAH051317-11 Adventist Health Clearlake Hospital, Inc. (Active) - information as of 4/25/2025 9:21:42 PM

Main Details

Name

Adventist Health Clearlake Hospital, Inc.

Subdivision Name

Adventist Health Medical Office Lakeport - Primary and Speciality Care

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051317-11

Medicare Provider Number

051317

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/10/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/29/2019

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

801 11th Street
Lakeport, CA 95453

Billing Address

Adventist Health Clearlake Hospital, Inc
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	ZZR00539G	1124018031,1871063040

Shipping Addresses

Same as Street Address

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 11:30:26 AM	8/18/2024 7:17:47 PM	8/18/2024 7:17 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 6:17:16 PM	9/6/2023 11:30:26 AM	9/6/2023 11:30 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 6:25:11 PM	9/16/2022 6:17:16 PM	9/16/2022 6:17 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 5:07:02 PM	9/9/2021 6:25:11 PM	9/9/2021 6:25 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/16/2020 5:07 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1871063040	9/16/2020 5:07 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/16/2020 5:07 PM
Details	Last Recertification Date	Update	Recertification		9/16/2020 5:07:02 PM	9/16/2020 5:07 PM
Details	Entity Name	Update	Change Request	St Helena Hospital Clearlake	Adventist Health Clearlake Hospital, Inc.	7/15/2020 10:10 AM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	7/29/2019 4:18 PM
Details	340B ID	Update	New Registration		CAH051317-11	7/29/2019 4:18 PM
Details	Entity Name	Update	New Registration	ST. HELENA HOSPITAL CLEARLAKE	St Helena Hospital Clearlake	7/29/2019 4:18 PM
Details	Entity Subname	Update	New Registration	Adventist Health Medical Office Lakeport	Adventist Health Medical Office Lakeport - Primary and Speciality Care	7/29/2019 4:18 PM
Dates	Participating Approval Date	Update	New Registration		7/29/2019 4:18:54 PM	7/29/2019 4:18 PM
Details	State	Update	New Registration	Pending	Approved	7/29/2019 4:18 PM
Dates	Signed By Date	Update	New Registration		7/23/2019 6:18:12 AM	7/29/2019 4:18 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/29/2019 4:18 PM
Addresses	Main Address	Insert	New Registration		801 11th Street Lakeport, CA 95453	7/10/2019 3:12 PM
Addresses	Billing Address	Insert	New Registration		Adventist Health Clearlake Hospital, Inc 15630 18th Avenue Clearlake, CA 95422	7/10/2019 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/10/2019 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ZZR00539G	7/10/2019 3:12 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/10/2019 3:12 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124018031	7/10/2019 3:12 PM
Contacts	Primary Contact	Insert	New Registration		Shelton, Jacarre Director of Pharmacy St Helena Hospital Clearlake 7079955800	7/10/2019 3:12 PM
Contacts	Authorizing Official	Insert	New Registration		JACOBSON, CARLTON CFO St Helena Hospital Clearlake 7079955824	7/10/2019 3:12 PM
Details	Last Recertification Date	Insert	New Registration			7/10/2019 3:12 PM
Details	Grant Number	Insert	New Registration			7/10/2019 3:12 PM
Details	340B ID	Insert	New Registration			7/10/2019 3:12 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/10/2019 3:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/10/2019 3:12 PM
Details	Medicare Provider Number	Insert	New Registration		051317	7/10/2019 3:12 PM
Details	Entity Name	Insert	New Registration		ST. HELENA HOSPITAL CLEARLAKE	7/10/2019 3:12 PM
Details	Program Code	Insert	New Registration		CAH	7/10/2019 3:12 PM
Details	Entity Subname	Insert	New Registration		Adventist Health Medical Office Lakeport	7/10/2019 3:12 PM
Dates	Participating Approval Date	Insert	New Registration			7/10/2019 3:12 PM
Details	State	Insert	New Registration		Pending	7/10/2019 3:12 PM
Dates	Registration Date	Insert	New Registration		7/10/2019 3:12:41 PM	7/10/2019 3:12 PM
Dates	Signed By Date	Insert	New Registration			7/10/2019 3:12 PM
Dates	Start Date	Insert	New Registration			7/10/2019 3:12 PM
Terminations	Termination Comments	Insert	New Registration			7/10/2019 3:12 PM
Terminations	Termination Date	Insert	New Registration			7/10/2019 3:12 PM
Terminations	Termination Effective Date	Insert	New Registration			7/10/2019 3:12 PM
Terminations	Termination Reason	Insert	New Registration			7/10/2019 3:12 PM