NPIMap

Organization Active NPI

Community Health Center of Fort Dodge, Inc.

  • Federally Qualified Health Center (FQHC)
  • Dayton, IA
National Provider Identifier
1689087215
Registry record updated Mar 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH CENTER OF FORT DODGE, INC.
Practice address
24 S Main St
Dayton, IA 50530
Phone
(515) 547-2974
Fax
(515) 547-2976
NPI assigned
Jun 11, 2014
Organization subpart
Yes
Parent organization
COMMUNITY HEALTH CENTER OF FORT DODGE INC.As reported in NPPES

Authorized official

NPPES NPI Registry
Name
Renae Irene Elizabeth Kruckenberg
Title
Ceo
Phone
(515) 576-6500

Owners & managing parties with NPI records 6

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

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 4

Organizations that report the same tax identification number in the National Provider Directory.

Facilities with the same owner 1

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

Practitioners 29

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 29

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
16D2085625Community Health Center of Dayton24 South Main Street, Dayton, IA 50530Provider-performed microscopyOct 16, 2026

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Federally qualified health center certification: CCN 161885

Medicare enrollment files
Legal name
COMMUNITY HEALTH CENTER OF FORT DODGE INC
Doing business as
COMMUNITY HEALTH CENTER OF DAYTON
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 20, 2018
Last certification
Aug 20, 2018
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
24 S Main St
Dayton, IA 50530-7698

All disclosed owners & managing parties 2

Medicare enrollment files

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

NameRoleSinceShare
Community Health Center of Fort Dodge Inc Organization, Fort Dodge, IA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2014 5%
5% Or Greater Security Interest Jul 1, 2014 5%
Operational/Managerial Control Jul 1, 2014 5%
Renae Kruckenberg Individual Corporate OfficerCeo Jul 1, 2014
Operational/Managerial ControlCeo Jul 1, 2014

All facility ownership & control disclosures 1

Medicare enrollment files

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Community Health Center of SpencerSpencer, IA, CCN 161040 Federally qualified health center 5% Or Greater Direct Ownership Interest (5%)
Operational/Managerial Control (5%)		 Jan 1, 2025
Jan 1, 2025

Medicare enrollment records 2

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20070104000109 IA Part B Supplier - Clinic/Group Practice 1557378627 Receives reassigned benefits from 33 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Spencer, IA; Mason City, IA; Fort Dodge, IA; Dayton, IA; Eagle Grove, IA; Clarion, IA
O20180820001950 IA Part a Provider - Federally Qualified Health Center (FQHC) 1557378627 Practice locations: Dayton, IA

National Provider Directory

National Provider Directory
Tax ID family
Community Health Center Inc (5 organizations share this tax ID)
Part of
Community Health Center Inc

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

NPPES NPI Registry

Primary practice location

24 S Main St
Dayton, IA 50530

Mailing address

24 S Main St
Dayton, IA 50530-7698
Phone (515) 576-6500

Other names 1

NPPES NPI Registry
  • Community Health Center of Dayton Other name

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Mar 1, 2023.

{
    "created_epoch": "1402444800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1677628800000",
    "number": "1689087215",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24 S MAIN ST",
            "city": "DAYTON",
            "state": "IA",
            "postal_code": "505307698",
            "telephone_number": "515-576-6500",
            "fax_number": "515-576-1951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 S MAIN ST",
            "city": "DAYTON",
            "state": "IA",
            "postal_code": "50530",
            "telephone_number": "515-547-2974",
            "fax_number": "515-547-2976"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTER OF FORT DODGE, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY HEALTH CENTER OF FORT DODGE INC.",
        "enumeration_date": "2014-06-11",
        "last_updated": "2023-03-01",
        "certification_date": "2023-03-01",
        "status": "A",
        "authorized_official_last_name": "KRUCKENBERG",
        "authorized_official_first_name": "RENAE",
        "authorized_official_middle_name": "IRENE ELIZABETH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "515-576-6500"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Health Center of Dayton",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Dayton, IA

Sources for this page

Verify at the official NPI Registry.