NPIMap

Organization Active NPI

Gypsum Creek Healthcare, Inc.

Doing business as Fort Dodge Health and Rehabilitation

  • Skilled Nursing Facility
  • Fort Dodge, IA
National Provider Identifier
1104110642
Registry record updated Feb 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
GYPSUM CREEK HEALTHCARE, INC.
Doing business as
Fort Dodge Health and Rehabilitation
Practice address
728 14TH Ave N
Fort Dodge, IA 50501-7016
Phone
(515) 576-7226
Fax
(515) 573-2865
NPI assigned
Jun 1, 2011
Last updated
Feb 23, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 23, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Soon Burnam
Title
Treasurer
Phone
(949) 540-1249

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X IA Primary

Addresses

Primary practice location

728 14TH Ave N
Fort Dodge, IA 50501-7016

Mailing address

728 14TH Ave N
Fort Dodge, IA 50501-7016
Phone (515) 576-7226

Other names 1

  • Fort Dodge Health and Rehabilitation Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service Other eSolutions Inc.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110719000595 IA Part A Provider - Skilled Nursing Facility 4587832530 Practice locations: Fort Dodge, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104110642. Details of each certification follow.

Skilled nursing facility certification: CCN 165156

Legal name
GYPSUM CREEK HEALTHCARE, INC.
Doing business as
FORT DODGE HEALTH AND REHABILITATION
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jul 17, 1990
Last certification
Jan 15, 2025
Beds
65
Ownership / control type
Corporation
Multi-facility organization
Ensign Services
Organization structure
CorporationProprietary
Enrollment address
728 14TH Ave N
Fort Dodge, IA 50501-7016
Nursing home name
FORT DODGE HEALTH AND REHABILITATION
Affiliated entity
THE ENSIGN GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Fort Dodge Health and RehabilitationCCN 165156 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
2 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Jul 17, 1990
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6559.7 residents per day on average
Chain
The Ensign Group342 facilities in the chain
Penalties (3 years)
2Fines totaling $166,043

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D0686629Gypsum Creek Healthcare728 14TH Avenue North, Fort Dodge, IA 50501Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lincoln R Wallace Individual Operational/Managerial Control Jul 5, 2024
Managing Control - Governing BodyMedical Director Jul 5, 2024
Adp of the SNF Jul 5, 2024
Elizabeth Hayden Individual Operational/Managerial ControlAdministrator Feb 26, 2016
Managing Control - Governing BodyAdministrator Feb 26, 2016
Adp of the SNF Feb 26, 2016
The Ensign Group Inc Organization, San Juan Capistrano, CA Corporation 5% Or Greater Indirect Ownership Interest Jul 18, 2011 100%
Adp of the SNF Jul 18, 2011
Ensign Services Inc Organization, San Juan Capistrano, CA Corporation Adp of the SNF Jun 1, 2011
Ami Sato Individual Corporate OfficerTreasurer Gypsum Creek Healthcare, Sep 9, 2024
David Jorgensen Individual Corporate DirectorDirector Gateway Healthcare LLC Jan 1, 2024
Gateway Healthcare LLC Organization, San Juan Capistrano, CA LLC 5% Or Greater Direct Ownership Interest Jul 18, 2011 100%
Debra K Koenig Individual Corporate OfficerPresident Gypsum Creek Healthcare, Sep 9, 2024
Chad Keetch Individual Corporate OfficerSecretary Ensign Services, Inc. Mar 1, 2011
Oleson Park Health Holdings LLC Organization, Mission Viejo, CA LLC Adp of the SNF Aug 28, 2014
Soon Burnam Individual Operational/Managerial Control Sep 9, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Lincoln R Wallace, MD
    • Family Medicine Physician
    • Fort Dodge, IA
    • NPI 1184696437

    Adp of the SNF, Managing Control - Governing Body, Operational/Managerial Control

    CMS ownership

Facilities with the same owner 18

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 18

Practitioners & affiliated clinicians

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306886400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614038400000",
    "number": "1104110642",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "728 14TH AVE N",
            "city": "FORT DODGE",
            "state": "IA",
            "postal_code": "505017016",
            "telephone_number": "515-576-7226",
            "fax_number": "515-573-2865"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "728 14TH AVE N",
            "city": "FORT DODGE",
            "state": "IA",
            "postal_code": "505017016",
            "telephone_number": "515-576-7226",
            "fax_number": "515-573-2865"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GYPSUM CREEK HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-01",
        "last_updated": "2021-02-23",
        "certification_date": "2021-02-23",
        "status": "A",
        "authorized_official_last_name": "BURNAM",
        "authorized_official_first_name": "SOON",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "949-540-1249",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113833.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CSV",
            "address_1": "8215 W 108th Ter",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101661",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Fort Dodge Health and Rehabilitation",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Fort Dodge Health and Rehabilitation",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Dodge, IA

Sources for this page

Verify at the official NPI Registry.